Elite Athletes and Pregnancy: Training, Performance, Health and Psychological Aspects Across Pre-, Peri-, and Postnatal Stages - A Scoping Review

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This scoping review summarizes the literature on training, performance, physical health, and psychological aspects before, during, and after pregnancy in elite athletes (tiers 3–5). The aim is to identify knowledge gaps and to inform future research. Methods: This review was conducted in accordance with the PRISMA-ScR guidelines and was registered with PROSPERO (CRD420250651470). At 8 th of January 2025, a systematic search of 10 databases (e.g., PubMed, Scopus, and PsycINFO) was conducted. Studies were eligible for inclusion if they involved elite female athletes during the pre-pregnancy, pregnancy, or postpartum phases. Data extraction included information on study design, athlete classification, training, health, performance, and psychological outcomes. Results: Of the 5,236 records examined, 102 studies met the inclusion criteria and 47 original research articles underwent detailed data extraction. Elite athletes often plan their pregnancies very carefully. Although high-performance training combined with a healthy diet does not necessarily impair fertility, some athletes reduce their training to support their fertility. Furthermore, there is no evidence to suggest that high training loads have a negative impact on the course of pregnancy. Evidence shows that elite athletes typically continue to train throughout pregnancy, adjusting the load, and resume training early after childbirth. Although highly individualized, performance recovery is feasible. Moderate-intensity exercise appears to be safe, but thresholds above 90% of maximum heart rate may impact fetal responses. Psychological stress, identity conflicts, and a lack of tailored guidelines are common challenges. Most birth outcomes match or exceed those of the general population. Conclusions: Despite the emergence of new evidence, there are still significant gaps in the research regarding individualized training protocols, postpartum return to sport strategies, and mental health interventions for elite athletes peri- and post-pregnancy. The current literature favors endurance sports and Western populations, highlighting the need for more diverse, prospective, and interdisciplinary research. Registration: The protocol for this review was registered in the PROSPERO database (CRD420250651470). gestation perinatal health high-performance athletes Olympic-level athletes female research hormones Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Key Points • Elite athletes are able to safely continue training during pregnancy and subsequently return to elite-level performance after childbirth. This necessitates individualized adaptations to training regimens and careful consideration of the athlete’s specific physiological and psychological changes during pregnancy and the postpartum period. • Future studies should categorize different sports into groups in order to develop specific training, postpartum recovery, and psychological support guidelines for elite athletes in each group. • Future studies should address underrepresented sport populations, employ prospective designs, and incorporate interdisciplinary care models. BACKGROUND The health benefits of exercise during pregnancy are widely acknowledged, including improved cardiovascular fitness, enhanced mental well-being, and positive effects on maternal and fetal health ( 1 – 4 ). Therefore, general recommendations promote physical activity during pregnancy. However, elite athletes face unique challenges due to the intensity, volume, and possible risks of their training. Existing guidelines often fail to provide specific advice tailored to their needs, highlighting the urgent need for further research ( 5 – 9 ). The participation of women in competitive sports continues to grow, so does the number of elite athletes who become pregnant. According to the Patient Rights Act, they have a right to comprehensive and evidence-based health information ( 10 ). However, the evidence base for the current recommendations appears insufficient. Therefore, a fundamental step is to gain a deeper understanding of pregnancy-related changes in musculoskeletal and functional characteristics, to improve and strengthen evidence-based information on safe and healthy exercise during pregnancy. The psychological implications of pregnancy and motherhood for elite athletes are significant, beyond the physical aspects. The transition to motherhood can provoke heightened stress and anxiety, as well as shifts in identity, particularly in relation to athletic performance and career expectations ( 11 , 12 ). It is crucial to address these psychological dimensions in order to develop multidisciplinary support systems that enable a balanced transition without compromising athletic careers ( 13 ). Returning to elite performance after childbirth presents further challenges, including physical recovery, managing mental health, and navigating new social dynamics ( 7 , 12 ). It is essential to understand these complex transitions in order to devise strategies that support elite athletes in regaining competitive form while managing the demands of motherhood. This scoping review systematically maps the current evidence on training, performance, physical health (including birth outcomes), and psychological aspects among elite female athletes throughout the pre-, peri-, and post-pregnancy periods. Unlike previous reviews, this review adopts a focused inclusion strategy that considers all types of original research and review articles involving elite athletes classified as tier 3 to tier 5 ( 14 ). This narrow focus enables a more precise understanding of this specific and understudied population. In doing so, the review not only incorporates newly published studies (up to 2025) that were not addressed in earlier syntheses, while also identifying relevant evidence that was previously overlooked. By applying rigorous and clearly defined eligibility criteria, this review provides a robust, targeted evidence base for aspects of training, performance, physical health, and psychological aspects throughout the entire continuum of pre-, peri- and postnatal stages. Our aim is to highlight persistent research gaps to inform future empirical studies. METHODS This scoping review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines (15). The review protocol was registered with the PROSPERO database (CRD420250651470). Figure 1 presents the flow chart of the study selection process. Eligibility Criteria The eligibility criteria for the literature included in this review were guided by the CoCoPopS framework (16)to identify appropriate studies. Population . The population of interest was elite female athletes classified as tiers 3-5 (14), who were highly trained and performed at a world-class level, with a minimum of eight hours of training per week. Athletes who appeared to belong to tier 3, but were not explicitly assigned to a classification in the article, were categorized based on other indicators (Appendix A1) and labeled with an asterisk (*). Inconclusive study groups comprising a significant proportion of elite female athletes identified by terms such as “competitive” or “professional” were also included in the analysis and labeled as a mixed group . Condition. The review focuses on the training of elite athletes before, during, and after pregnancy. The focus is on understanding the key factors athletes need to consider when becoming pregnant, training during pregnancy without endangering themselves or their unborn child, and returning to their optimal performance level after childbirth. These factors include training, performance, physical health, and psychological aspects. Context. Studies were eligible for inclusion if they reported on elite athletes at any point during pregnancy, and if the athletes were active in a high-performance sports environment at this time. Study. To capture all relevant original studies, reports, and reviews on the topic, primary research studies were eligible for inclusion, irrespective of their design. The focus was placed on original studies, encompassing randomized controlled trials, controlled trials, single-case, observational studies, and qualitative studies. Reviews, overviews and books or book chapters were also included to identify original studies that might have been overlooked during the initial search. Search Strategy and Study Selection To address the review questions, a preliminary search was conducted in January (2025), without restricting the year of publication. A structured search was then carried out across multiple electronic databases, including PubMed, MEDLINE, Cochrane, Web of Science, Scopus, PsycNet, EMBASE, PsycINFO, Sponet, and Surf. A sensitive search strategy was applied, incorporating free text terms pertinent to the research, and, where possible, focusing on titles and abstracts related to elite athletes and pregnancy. The full search strategy is detailed in Appendix (A2). The study selection process involved two independent raters (IT and JN), who screened the titles and abstracts of the identified studies to determine their relevance. In cases of uncertainty, the full text of the articles was retrieved for further evaluation. In the second step, the same raters assessed the full-text articles independently for final inclusion. Any discrepancies were resolved through discussion or by consulting a third or fourth reviewer (PP or KL). Additional articles were retrieved from the reference lists of included studies where applicable. Insert Figure 1 here Data Extraction Formal data extraction was performed for all the original articles included in the study (Table 1). Two raters (IT and JN) extracted the relevant data independently. The following data were extracted: author, year of publication, study design, population, context, condition, level of evidence, comparison, and outcome, along with the major findings. To provide a comprehensive understanding of the experience of elite athletes, the results were organized within a temporal framework comprising three main phases: before pregnancy, during pregnancy, and after pregnancy. Within each phase, the findings were categorized thematically into four domains: training, performance, physical health, and psychological aspects. Further, the findings on birth outcomes were summarized. The main outcomes were training and performance parameters, competitions, maternal and fetal heart rate, body weight, complications, symptoms, injuries, return to sport and competition, breastfeeding, fertility, safety concerns, advice, anxiety, and identity. If available, birth outcomes were documented as follows: birth weight, birth mode, onset of labor, length of labor, Apgar score, and complications. Insert Table “Data extraction” here RESULTS Current State of Literature In recent years, there has been a significant increase in the number of publications addressing pregnancy in elite athletes. A particular rise has been observed over the last two decades, with 16 studies being published in the last five years alone (compared to nine studies between 1970 and 1999, and 22 studies between 2000 and 2019). Characteristics of Included Studies Following a comprehensive search across multiple databases and citation tracking, a total of 5,236 records were identified (Figure 1). After removing duplicates, 3,927 articles underwent title and abstract screening. Of these, 3,623 were excluded based on predefined criteria. Full texts of 302 articles were assessed for eligibility, resulting in the exclusion of 200 studies due to reasons such as absence of focus on pregnancy, lack of elite athlete populations, policy-focused content, duplicate publication, or missing full-text availability (not even in the largest medical library in Germany, the Central Medical Library in Cologne). Ultimately, 102 studies were included in the scoping review. Of these, 55 were categorized as review or overview articles (Appendix A3), while the remaining 47 were original research articles that underwent detailed data extraction. Compared to the last available scoping review (17), which included only 16 original studies, this review identified and extracted a total of 47 original studies for inclusion in the dataset. Further, compared to another review (18), which also incorporated all available literature (including reviews and mixed methods) and comprised 40 studies in total, this scoping review's search strategy yielded 102 studies related to the topic of pregnancy and elite sport. The extracted original studies comprised various designs: six were experimental studies, eight were cross-sectional studies, seven were observational cohort studies, four were case–control studies, nine were case reports or series, and 13 were qualitative studies. Six of the 47 studies were dataset duplicates, which were included in the data extraction due to different research questions or selection parameters. Mapping of Key Outcome Parameters Frequency analysis illustrates the distribution of outcome parameters such as training, performance, physical health, and psychological aspects before, during, and after pregnancy, as well as birth outcomes in relation to study design and sample size (Figure 2). It is evident that there is a paucity of experimental studies (n=5), and, among these, a particular absence of randomised controlled trials (n=0). Furthermore, most cross-sectional and cohort studies are retrospective, which fundamentally reduces the strength of the overall evidence. A total of five experimental studies, eight cross-sectional studies, seven cohort studies, four case–control studies, nine case reports or series, and 12 qualitative studies were included in the frequency analysis. One experimental study and one qualitative study were excluded due to duplication. Insert Figure 2 A and B here Before Pregnancy Training Elite athletes often become pregnant while still training with high volumes and intensities, and typically maintaining their usual training routines until the pregnancy is confirmed (9). Several studies indicate that women engage in 5 to 16 hours of training per week prior to conception (9,19,20). In specific disciplines such as running or judo, some athletes (24-57%) intentionally reduced training intensity or volume to support fertility or to align conception with planned career transitions (12,21,22). Performance Seven out of eight Olympic-level athletes typically planned their pregnancies to avoid disrupting their peak performance periods (12,23). Some athletes used the time during pregnancy to rest and recover from injuries (12). Physical Health Most athletes who engage in elite training prior to pregnancy do not appear to experience negative effects on fertility or pregnancy outcomes (9,23,24). However, 23% of endurance athletes have reported irregular menstrual cycles or amenorrhea, alongside concerns about previous miscarriages potentially being linked to high training volumes (25). For elite athletes, planning for pregnancy can be particularly challenging, as they must balance reducing training to optimize fertility with maintaining competitive performance (22). Overall, athletes are generally found to be healthier than non-athletic controls, displaying higher levels of education and lower rates of smoking and chronic health conditions (26). Psychological Aspects The psychological burden of planning a pregnancy while pursuing an elite sport career can be significant. Many athletes reported being afraid of losing their team positions or sponsorships if they disclosed their pregnancies (22). The social pressure to choose between motherhood and athletic ambition can lead to significant internal and external conflict (22,27). Peer support and sharing experiences with other athlete-mothers emerged as essential sources of reassurance and emotional resilience (20). During Pregnancy Training Across the studies, the majority of elite athletes continued to train during pregnancy. Training volume and intensity generally remained stable during the first trimester, but decreased gradually as the pregnancy progressed, particularly in the third trimester (9,21,28–31). While sport-specific training usually decreased, non-specific training, such as cycling, walking, cross training, and strength training, increased (Figure 3). Training typically shifts towards lower-intensity, non-contact activities such as swimming, walking, and cycling. High-intensity or sport-specific activities, such as jumping and contact sports like judo or netball, were often stopped due to safety concerns or physical changes (20,30,31). Insert Figure 3 here Several studies have investigated heart rate thresholds that are considered safe for training during pregnancy among elite athletes. In one study, a conservative threshold of <140 beats per minute was adopted by 42% of participants (28), though 39% preferred subjective measures, such as perceived exertion, to a fixed upper limit of heart rate during exercise. More detailed physiological assessments suggest that training within 50–75% of heart rate reserve is generally safe, with no adverse fetal outcomes reported (32). One study examined the effects of strenuous treadmill exercise at 60–90% maximum oxygen uptake (V̇O 2max ) during the second trimester (23–29 weeks of gestation). The study found that fetal heart rate remains within normal limits when the maternal heart rate stays below 90% of its maximum. However, exercise exceeding this threshold led to reduced arterial uterine blood flow and transient fetal bradycardia, which resolved post-exercise. This indicates that the maternal heart rate should remain below 90% of its maximum to minimize potential fetal compromise (33). In addition, another study showed that transient fetal heart rate decelerations and elevated umbilical and uterine Doppler indices occurred in five highly active pregnant women subsequent to strenuous treadmill exercise. However, no enduring impairment of fetal well-being was observed (34). There is also evidence of longitudinal cardiovascular adaptations during pregnancy, including increased maternal heart rates during rest and submaximal exercise (35–37). These findings suggest that pregnancy increases cardiovascular load even at submaximal intensities, highlighting the importance of personalized monitoring despite the lack of clearly defined heart rate thresholds. A considerable number of athletes have reported a preference for subjective metrics, such as perceived exertion, or “listening to the body” approaches. These strategies are frequently described as “go with the flow” approaches (20,28,30,38). Compared to the year prior to pregnancy, athletes do not reduce their weekly duration of low-intensity training during the first trimester compared to the year prior to pregnancy (452 ± 300 minutes per week) (30). Most athletes stopped competing after the first trimester, citing physical changes and risk aversion as the main reasons (20,25,30). Several studies indicate that elite athletes continued strength and core training during pregnancy, often modifying their training to accommodate physiological changes and mitigate injury risk. Training typically focused on the pelvic floor, abdominal and lower limb muscles, particularly in the later stages of pregnancy, to prevent dysfunction (30,39,40). Athletes tended to choose low-risk activities such as swimming, cycling, and stabilization exercises while avoiding high-impact or abdominally stressful movements (20). However, a lack of evidence-based guidance on strength training during pregnancy is frequently reported, leading many athletes to rely on peer networks or self-directed adaptations (9,29). More broadly, athletes consistently cite peer support or personal experience as their primary source of guidance, due to the ongoing absence of expert advice tailored specifically to elite performance contexts (22,29). Performance Some studies have examined the impact of pregnancy on athletic performance. These studies have observed increased cardiovascular responses, including elevated resting heart rate and reduced V̇O 2max , while submaximal performance capacity has remained largely stable (35,37). Another study demonstrated that V̇O 2max remains stable during endurance testing in pregnancy, while resting oxygen uptake increases, maximum carbon dioxide production decreases and hyperventilation persists. A slight reduction in maximum heart rate was also observed (42). A study comparing high- and medium-volume exercise groups during pregnancy found no significant differences in skinfold thickness, blood values, or perceived exertion. However, maternal resting heart rate increased during pregnancy, and only the high-volume group showed an improvement in oxygen consumption at maximal load. This finding suggests that, despite variing baseline capacities, there is comparable overall response to exercise (19). While many elite athletes continued to participate in competitions during the first trimester of pregnancy, the majority subsequently reduced or ceased competitive activity from the second trimester onward (25,29,30,39). While performance-focused training was generally avoided during this period, some athletes continued to engage in technical skill and strength training (30,40,43). Physical Health The health effects of high-performance training during pregnancy are still being debated. However, the majority of studies suggest that moderate-intensity exercise does not have a negative impact on maternal or fetal health (19,25,32). Although physiological adaptations such as an elevated maternal heart rate and slower core temperature recovery post-exercise have been documented, peak temperatures have remained within safe limits (44). While moderate-intensity exercise is generally well tolerated, high-intensity training exceeding 90% of the maximum heart rate (33) and repeated sprint efforts (36) were identified as critical thresholds. Transient fetal bradycardia was observed in these instances. Serious complications are rare, with only a few cases of mild pre-eclampsia, obstetric cholestasis, altered liver enzymes, and HELLP syndrome reported. None of these were conclusively linked to physical activity (33,37,45). Other reported complications include general pregnancy disturbances (30%) (23), anemia (27%), and miscarriage or preterm birth (10.7%). However, no significant differences were found between athletes and controls (46). One study found that 23% of participants had previously experienced a spontaneous abortion, with five participants attributing this to intense training (25). Common symptoms during pregnancy include back pain, fatigue, nausea, dizziness, urinary incontinence, and musculoskeletal discomfort, particularly in the third trimester (20,29,36). However, elite athletes reported similar or even fewer pregnancy-related complaints compared to the control groups (9,43). Although the overall injury incidence is low, individual cases of stress fractures, ankle sprains, and muscle strains have been documented (9). Notably, a study revealed that 98.2% of athletes in one cohort reported no injuries during pregnancy (39). The average gestational weight gain among elite athletes is between 9 and 14 kg. Those engaged in high-level competition are more likely to exceed the Institute of Medicine's (IOM) recommendations slightly (13.7-16.1 kg) (39,47). Notably, the majority of athletes (96%) reported an overall uncomplicated pregnancy experience with few or no significant symptoms (39). Psychological Aspects Psychologically, pregnancy is a time of heightened uncertainty and emotional ambivalence for elite athletes. Many reported increased anxiety due to a lack of evidence-based guidance on safe training, coupled with fears that continued physical activity might affect fertility or the health of the fetus (22,29,48). The social and institutional pressure to choose between elite sport and motherhood intensifies this emotional strain further, contributing to conflicts of identity and concerns about career security (22,27,49,50). Pregnancy is often treated like an “injury,” meaning athletes receive no pay if they are not competing, which in turn pressures them to continue training or return to competition during pregnancy or shortly after giving birth (50). Athletes often struggle with changes in body image and self-perception, as well as fears of a decline of performance (22,48). However, studies also highlight the potential benefits of psychopedagogical interventions, such as relaxation training and counseling, which can significantly reduce anxiety and depressive symptoms during pregnancy (41). Despite these psychological challenges, some athletes reported positive emotional engagement with their changing bodies, describing pregnancy as a time of physical and mental renewal (12). Notably, peer support and shared experiences with other athlete mothers emerge as crucial sources of reassurance, motivation, and resilience throughout the pregnancy journey (20). After Pregnancy Training The time it takes to return to training after childbirth varies from person to person, but it often happens earlier than the return to recreational sports in the general population. Many athletes resumed light activities, such as pelvic floor exercises, walking, or functional workouts, within the first six weeks after childbirth (9,20,40). Most elite athletes resumed training within 6–12 weeks postpartum (9,21,30). More intense sessions typically follow after 8-12 weeks. 80% of pre-pregnancy training load was typically achieved within 14 ± 11 weeks (21). The pre-pregnancy training volume was usually achieved within 3-9 months (23,30,39). The time taken to return to training after a cesarean birth varies (30,46). Studies also report coordination difficulties due to sleep deprivation and breastfeeding, which impacts training (21,51). Darroch et al. (2023) observed that those who maintained higher training volumes in the first and second trimesters had better postnatal performance outcomes (21). Performance The postpartum period is accompanied by the following physiological changes: a decrease in maternal heart rate, an increase in blood lactate concentrations, an early peak in oxygen uptake, and a slight reduction in vital capacity (35). Many athletes successfully returned to their peak athletic performance, albeit at different speeds. Studies have shown that athletes can regain their pre-pregnancy performance levels (23,38,39) or even achieve personal bests (21,28,36,52). One study found that 11% of athletes improved, 61% returned to the same level of performance, and 28% did not return to their previous level of performance after pregnancy (25). In another study, 44% of athletes indicated that they had returned to the same level of performance, 15% reported an improvement in performance, while 26% exhibited a deterioration, and 15% were unsure (9). The rate of recovery is significantly influenced by several factors, including the duration of breastfeeding, the volume of training during pregnancy and the postpartum period, and individual characteristics (21). Additionally, the ability to return to sport and improve performance primarily depends on the age at which the athletes become pregnant, relative to their respective peak performance ages (52). Postpartum sprint intervals or targeted endurance training have been shown to rapidly restore cardiovascular markers (53,54). Physical Health Typical postpartum health issues affect the musculoskeletal system, causing problems such as pelvic floor weakness, rectus diastasis, and stress fractures, as well as back pain and incontinence (12,46,55). Despite these challenges, many athletes reported a stable recovery and return to normal physical performance within a year (9,56). Breastfeeding, although logistically demanding, is often continued alongside training; however, potential impacts on performance may arise from sleep disruption or challenges related to milk supply. At this stage, it is crucial to ensure that athletes are drinking enough fluids (11,51) . Psychological Health The psychological outcomes in the studies are mixed: female athletes reported newly gained strength and determination as a result of motherhood. However, they also report feelings of insecurity, excessive demands, and depressive symptoms, particularly due to social expectations and the tension between career and motherhood (11,55,57). Motherhood was reported to be perceived as a transformative experience (58). Athletes reported improved life balance, increased motivation, and a redefined athletic identity (38,57). Emotional struggles includ feelings of guilt, pressure, and difficulties to return to sport, loss of squad status and difficulty reconciling changes to the body with athletic goals (11,49,55). Emotional and mental support from the immediate environment was specified as a key resource (49). The identity of being both “athlete” and “mother” was often redefined and served as a source of motivation and inspiration (50,57). However, a lack of professional psychosocial support remains a significant issue (58,59). Birth Outcomes The birth outcomes of elite athletes appear to be largely comparable to, or even slightly better than, those of the general population. Several studies reported high rates of spontaneous vaginal delivery (~70%) (Figure 4) and healthy Apgar scores after five minutes (>7), with no differences observed compared to controls (32,39,46). Cesarean section rates vary, but are not elevated in most elite cohorts compared to controls (24,39,60). Insert Figure 4 here Importantly, no consistent negative effects of intense or sustained training on labor or neonatal outcomes have been demonstrated. Studies comparing elite athletes to non-athletes showed no significant differences in birth mode, duration of labor, need for interventions, complications or neonatal health metrics (23,25,60,61). However, some data suggest an increased likelihood of prolonged labor among highly trained women, potentially due to stronger pelvic musculature (23). Birth weight generally falls within normal ranges, with an average value of 3.403 ± 487 grams (Figure 5). However, contradictory findings have been reported in the literature. Some studies reported slightly higher weights in conjunction with increased maternal exercise intensity (28), while others reported lower weights in endurance athletes with high training volume (33). Perineal injuries and interventions (e.g., episiotomies) were reported in line with general trends and were not consistently correlated with athletic status (24,60). Insert Figure 5 here Overall, the available evidence supports the idea that participation in elite-level sports during pregnancy is not associated with adverse birth outcomes, provided that training intensity and volume is appropriately moderated and medical supervision is in place. DISCUSSION This review provides a unique, comprehensive, and up-to-date overview of the current state of research on pregnancy and elite sports. By systematically searching 10 different databases, a more extensive array of original articles has been included than in any previous review on the topic. Furthermore, it identifies and discusses existing research gaps with the aim of fostering systematic development in original experimental research studies. This work reveals the growing prominence of pregnancy in elite sports, while also highlighting significant gaps that hinder the development of concrete, evidence-based guidelines. Notably, much of the current literature is predicated on a limited number of original studies, emcompassing limited sample sizes, single-case reports, or retrospective designs. This severely restricts the ability to generalize, particularly with regard to fertility, training load, intensity thresholds during pregnancy, and the timing of the postpartum return to sport. Fertility There are inconclusive findings regarding the impact of elite sports on female fertility. In general, athletes with a mean training volume of around 15 hours per week can maintain their training load when the energy status is balanced and when planning to conceive without severe reproductive consequences ( 9 ). However, the combination of high-performance training and the Relative Energy Deficiency Syndrome in Sports (REDs) has been shown to result in a deterioration of reproductive function, independent of total weekly training hours ( 62 ). The majority of studies have exclusively included female athletes who have experienced successful pregnancy. A high number of unreported cases of fertility disorders may exist among athletes who were not examined within the scope of these studies. Moreover, miscarriages may be substantially underreported among elite athletes, partly due to social stigma and a paucity of open discussion ( 63 ). Therefore, it is necessary to systematically compile and analyze medical data on this population to comprehensively understand the extent of the reproductive health risks and outcomes faced by highly trained female athletes. Training load The ongoing reliance on subjective metrics, including perceived exertion and self-monitoring, underscores a notable absence of standardized physiological benchmarks ( 20 , 28 , 30 , 38 ). Recommendations on maternal heart rate during pregnancy, for example, are predominantly derived from single experimental studies ( 32 , 33 ) and cannot yet serve as robust guidelines. Similarly, the hypothesis that training below 90% of maximum heart rate ( 33 ) or within 50–75% of heart rate reserve ( 32 ) is “safe” is not supported by high-level evidence. This hypothesis requires replication and confirmation through larger controlled trials. The absence of standardized, sport-specific recommendations means that athletes depend significantly on self-monitoring and peer advice ( 20 , 22 ). While this strategy emphasizes physical autonomy, it can also expose athletes to the risks of overtraining, injury, and inadequate postpartum recovery. In our view, the assertion that moderate exercise intensity can be gauged by the ability to still speak during exercise (the “talk test”) or by means of perceived exertion scales ( 64 ) is inadequate for evidence-based recommendations concerning training management. With respect to the management of training loads, the data indicates that elite athletes adjust their training volume, intensity, and type during pregnancy. However, the optimal “safe” ranges remain unresolved. Furthermore, a systematic comparison with general recommendations for recreationally active pregnant women has not been undertaken ( 30 ). The systematic documentation of weekly training loads, as referenced in studies ( 31 , 40 , 45 , 54 ), is needed. The development of single sport-specific recommendations on training adjustments during pregnancy appears to be an unrealistic objective at this time. Consequently, further research is necessary into specific sports groups, including endurance sports, team sports, high-impact sports, and explosive strength sports. Ideally, phase-specific documentation of training and health data should be organized according to gestational age in weeks, or at least in trimesters, to help move beyond inconsistent descriptive data and derive general recommendations. Recommendations regarding resistance training during pregnancy are neither uniform nor consistently evidence-based. Thus, the question remains as to how muscle strength and muscle tone, particularly that of the pelvic floor, influence the course of labor and delivery ( 65 ). For instance, it is unclear whether strengthening the already strong pelvic floor of elite athletes would have a positive or negative impact on the progression of childbirth. Return to sport Postpartum return to sport patterns are highly individualized. While many athletes successfully return to or surpass pre-pregnancy levels of training loads and performance ( 21 , 39 , 52 ), this process is influenced by factors, such as breastfeeding, sleep deprivation, injury history, and psychosocial support ( 51 , 55 ). However, the current evidence base is largely comprised of self-reported retrospective outcomes, which introduces the potential for bias that could mask underlying vulnerabilities, particularly with regard to pelvic floor health or injury recurrence ( 12 , 46 ). Interestingly, athletes often report fewer common pregnancy-related issues than recreationally active women, potentially due to superior baseline fitness and body awareness ( 9 ). Nevertheless, clear medical guidance on sport-type-specific risks and considerations is lacking and urgently needed, particularly in disciplines where body mass plays a crucial role (e.g., aesthetic or weight-class sports) or where strong abdominal muscles are essential, especially with regard to injury prevention and pelvic floor health. Psycological dimensions In terms of psychological aspects, motherhood can be a source of both empowerment and significant stress ( 57 – 59 ). Identity conflicts, social pressures, and sponsorship concerns can exacerbate these challenges ( 11 , 22 ). Data suggest that successful return to sport depends on physical readiness as well as psychosocial, logistical, and financial support systems. Having individualized recovery plans that set out the competencies to be achieved during the postpartum period, alongside a structured reintegration into competition, could reduce risks, and support sustainable performance improvements. While there is some evidence to suggest psychological benefits, such as enhanced resilience ( 38 ), the formal evaluation of mental health interventions using standardized tools, such as validated questionnaires, remains rare ( 41 ). Birth outcomes Finally, the birth outcomes of elite athletes seem to be largely similar to those of the general population ( 24 , 39 , 60 ). However, it should be noted that these findings are based on small, heterogeneous samples, so they should be interpreted with caution. Observations regarding prolonged labor or slight deviations in neonatal weight suggest potential physiological adaptations ( 23 , 33 ). Nevertheless, further systematic research specific to different sports is essential before definitive conclusions can be drawn. Research Gaps and Future Directions In light of these gained insights, future research should prioritize high-quality experimental and prospective studies involving larger and more diverse cohorts of athletes. Interventions combining individualized training prescriptions, standardized physiological monitoring, and comprehensive psychosocial support should be systematically developed and evaluated. Furthermore, long-term follow-up is necessary to assess sustained health and performance trajectories, as well as immediate postpartum outcomes. The present review emphasizes the necessity of systematic, in-depth descriptive documentation, and the advancement of more mechanistic and interventional research. Closing these evidence gaps is essential to developing meaningful, sports group-specific guidelines that go beyond anecdotal strategies and provide genuine support for athletes and mothers at the highest level. Notwithstanding the mounting involvemen of women in high-performance sports, the available evidence remains fragmented (Fig. 6). The majority of studies utilize retrospective designs, small sample sizes, and self-reported data. Notably, there is a lack of prospective, sports group-specific studies examining the physiological, psychological, and performance-related changes across the entire peri-pregnancy timeline. A paucity of studies exists that provide structured, evidence-based return to sport protocols, and even fewer address the long-term career trajectories of athlete mothers. Furthermore, psychological dimensions such as identity negotiation, postpartum mental health, and societal expectations are underrepresented in quantitative research. The current literature also favors endurance sports in Western contexts and offers limited insights into team sports, weight-class sports, or para-sport disciplines. Addressing these disparities is imperative for the development of effective, personalized support systems and policies that reflect the realities of elite sport and motherhood. Insert Fig. 6 here Longitudinal, prospective studies with larger sample sizes are urgently needed to generate robust data that can inform policy, medical practice, and coaching strategies. The extant body of research is predominantly composed of retrospective, qualitative, or single-case studies. However, the dearth of studies employing longitudinal, controlled, or interventional designs, compromises the extent to which robust conclusions can be drawn. Additionally, the absence of standardized outcome measures across studies complicates the synthesis and comparison of findings, impeding the establishment of clear conclusions. CONCLUSION This scoping review underscores the intricate interplay of physiological, psychological, and social factors that influence the experiences of elite female athletes during pregnancy and the postpartum period. Despite the increasing recognition of the advantages of continuing to train during pregnancy, elite athletes are still not receiving the evidence-based, sport group-specific guidelines they need to address their unique requirements and performance objectives. The extant literature underscores the remarkable physical adaptability of athlete-mothers and their promising return to performance trajectories. However, these positive outcomes are frequently attained in the absence of standardized medical and coaching frameworks, thereby exposing athletes to potential risks, particularly relating to injury and inadequate postpartum recovery. Furthermore, the transition to motherhood constitutes a substantial psychological and social transformation. While this phenomenon may be empowering for some, it concomitantly engenders significant emotional challenges. The dual identity of athlete and mother has been demonstrated to be a source of resilience and renewed motivation. However, there is a clear need for targeted mental health support and integrated psychosocial interventions. This review uncovers significant gaps in the current evidence base, particularly with regard to prospective, sport group-specific research across diverse athletic disciplines and cultural contexts. There is an urgent need for longitudinal studies that employ standardized outcome measures. These studies are necessary to inform the development of tailored training adaptations, return to sport protocols, and multidisciplinary support strategies. Addressing these disparities is imperative for developing comprehensive, personalized guidelines that facilitate the safe and sustainable pursuit of athletic excellence by elite athletes while ensuring the optimal conditions for motherhood. In order to accomplish the aforementioned research objectives, it is imperative to establish an international collaborative research network. This network will assure that sample sizes are sufficiently large and diverse across sports, regions, and performance levels. Abbreviations V̇O 2max : Maximum oxygen uptake Declarations Ethics approval and consent to participate According to the responsible ethics committee, no formal ethics approval was required for this study, as it is based exclusively on the evaluation of data that are already publicly accessible and have been previously published in the scientific literature. Consent for publication Not applicable. Availability of data and material All the data analyzed during this scoping review are included in the published article, in the tables that summarize the included studies. The corresponding author can provide reasons for the exclusion of studies. Competing interests Jana Nolte, Isabell Thal, Emily Büthe, Susanne Weber, Petra Platen and Kirsten Legerlotz declare that they have no competing interests relevant to the content of this review. Funding This project was funded by the Federal Institute for Sports Science (BISp) based on a decision by the German Bundestag (ZMI4-080118/24). Ruhr University Bochum enabled Open Access funding. Authors' contributions Conceptualization: PP and KL; Search: JN and IT; Title, abstract and full text screening: JN and IT; Data extraction: JN and IT; Drafting: JN; Creation of figures and tables: JN; Critical review of the manuscript: IT, EB, SW, PP and KL. All authors read and approved the final version. 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Supplementary Files SupplementaryMaterialEliteathletesandpregnancy.docx Cite Share Download PDF Status: Published Journal Publication published 09 Mar, 2026 Read the published version in Sports Medicine-Open → Version 1 posted Editorial decision: Major Revision 27 Nov, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers invited by journal 14 Oct, 2025 Editor invited by journal 13 Oct, 2025 Editor assigned by journal 08 Oct, 2025 First submitted to journal 07 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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07:02:21","extension":"png","order_by":28,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":109032,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure5.png","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/7442c806c0d77061b67a5868.png"},{"id":94635940,"identity":"be4296c2-1f2e-43b8-bfd7-d36aa84dbcd7","added_by":"auto","created_at":"2025-10-29 07:02:21","extension":"png","order_by":29,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68249,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure6.png","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/7e8f7e194ab68922a19d72a7.png"},{"id":94635948,"identity":"57026655-f7ba-4450-8a60-2acb5a9cf2b5","added_by":"auto","created_at":"2025-10-29 07:02:21","extension":"xml","order_by":30,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":153936,"visible":true,"origin":"","legend":"","description":"","filename":"SMOAD25006650structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/4a7b61fad55f3c0e00105393.xml"},{"id":94640580,"identity":"09115d2a-b563-4dd6-818a-70642941d9f7","added_by":"auto","created_at":"2025-10-29 07:49:52","extension":"html","order_by":31,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":165842,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/92100c24497a68bb424074e4.html"},{"id":94635913,"identity":"607f26ee-8ee3-48ed-bfe9-9bb8e17e66ff","added_by":"auto","created_at":"2025-10-29 07:02:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54403,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the study selection process (8-29 January 2025).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/346b3749fd7ecc93f5263340.png"},{"id":94640496,"identity":"3cb5e0fa-9905-4bd2-bd59-27d005eb1e03","added_by":"auto","created_at":"2025-10-29 07:49:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":230057,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency analysis. Key outcome parameters (training, performance, physical health, and psychological aspects) before, during, and after pregnancy, as well as birth outcomes are categorized by study design. Bubble size and numbers within the bubbles indicate either the number of studies (A) or the total sample size (B). The grey boxes above the figure show the total number of studies (A) and participants (B) for the different outcome parameters. The study designs on the y-axis are ordered by the strength of the evidence according to the 2011 Levels of Evidence from the Oxford Centre for Evidence-Based Medicine. Qualitative studies are shown separately at the bottom, as they do not fit into the hierarchy, but they provide valuable contextual and experiential insights.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/14bdd3b37df58071fa57cf23.png"},{"id":94635914,"identity":"9d9a5fb2-9af5-40dc-aa95-29ba722f34f0","added_by":"auto","created_at":"2025-10-29 07:02:21","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":108721,"visible":true,"origin":"","legend":"\u003cp\u003eTraining load distribution across pregnancy trimesters by training type. Percentage in training loads in different types of training (endurance training, strength training, unspecific or alternative training, and total training) in the 1\u003csup\u003est\u003c/sup\u003e, 2\u003csup\u003end\u003c/sup\u003e and 3\u003csup\u003erd\u003c/sup\u003e trimester as indicated in the respective studies. The percentages were either converted from the original data or read from the respective figures. Therefore, they should be interpreted accordingly. Cohen et al. (1989): n=2, running (miles per week); Darroch et al. (2023): n=42, running (kilometres per week); Davies et al. (1999): n=1, running (kilometres per week) (twins); Sundgot-Borgen et al. (2019): n=34, endurance training (minutes per week); Solli \u0026amp; Sandbakk (2018): n=1, specific training (cross-country skiing, skating and classical) (hours per week); Sundgot-Borgen et al. (2019): n=34, strength training (minutes per week); Darroch et al. (2023): n=42, cross training (minutes per week); Solli \u0026amp; Sandbakk (2018): n=1, unspecific training (running, walking, and cycling) (hours per week); Beilock et al. (2001): n=26, cardio and strength training (FIT index); Solli \u0026amp; Sandbakk (2018): n=1, overall training (hours per week).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/4cfc14368f2192a32cb2d2b7.png"},{"id":94635915,"identity":"c5098208-807f-41d1-9b92-e705fcc2f10a","added_by":"auto","created_at":"2025-10-29 07:02:21","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":140525,"visible":true,"origin":"","legend":"\u003cp\u003eBirth mode. Frequency distribution of two birth modes among elite athletes in selected studies: vaginal births (including induced labor and assisted deliveries) and cesarean sections (including elective and spontaneous procedures).\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/aa49445784daafd889bc92d4.png"},{"id":94640158,"identity":"1697bf4e-baab-440b-9529-6e3dd41ef380","added_by":"auto","created_at":"2025-10-29 07:48:34","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":118829,"visible":true,"origin":"","legend":"\u003cp\u003eBirth weight. Mean values (light grey bars) and, if available, the respective standard deviations of birth weights of babies from elite athletes in selected studies. The mean value of all studies is represented by the dark grey bar.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/d047802e400215b23b5fd2ad.png"},{"id":94635922,"identity":"4ff5eebc-98a2-4573-93e7-eb51ebc9387d","added_by":"auto","created_at":"2025-10-29 07:02:21","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":129090,"visible":true,"origin":"","legend":"\u003cp\u003eKey research gaps identified in this scoping review on pregnancy in elite sports.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/475d9e537f63a995fc6cbf2b.png"},{"id":104739321,"identity":"aac7fe39-9222-4309-852b-4dc183357996","added_by":"auto","created_at":"2026-03-16 16:01:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1656645,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/04795907-1114-494f-9775-418ad2d591c2.pdf"},{"id":94640686,"identity":"b979adf8-042c-4fd3-b0b6-edc681853711","added_by":"auto","created_at":"2025-10-29 07:50:05","extension":"docx","order_by":14,"title":"","display":"","copyAsset":false,"role":"supplement","size":32436,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialEliteathletesandpregnancy.docx","url":"https://assets-eu.researchsquare.com/files/rs-7764218/v1/6da77a38ff9fd96aa6472cea.docx"}],"financialInterests":"","formattedTitle":"Elite Athletes and Pregnancy: Training, Performance, Health and Psychological Aspects Across Pre-, Peri-, and Postnatal Stages - A Scoping Review","fulltext":[{"header":"Key Points","content":"\u003cp\u003e\u0026bull; Elite athletes are able to safely continue training during pregnancy and subsequently return to elite-level performance after childbirth. This necessitates individualized adaptations to training regimens and careful consideration of the athlete\u0026rsquo;s specific physiological and psychological changes during pregnancy and the postpartum period.\u003c/p\u003e\u003cp\u003e\u0026bull; Future studies should categorize different sports into groups in order to develop specific training, postpartum recovery, and psychological support guidelines for elite athletes in each group.\u003c/p\u003e\u003cp\u003e\u0026bull; Future studies should address underrepresented sport populations, employ prospective designs, and incorporate interdisciplinary care models.\u003c/p\u003e"},{"header":"BACKGROUND","content":"\u003cp\u003eThe health benefits of exercise during pregnancy are widely acknowledged, including improved cardiovascular fitness, enhanced mental well-being, and positive effects on maternal and fetal health (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Therefore, general recommendations promote physical activity during pregnancy. However, elite athletes face unique challenges due to the intensity, volume, and possible risks of their training. Existing guidelines often fail to provide specific advice tailored to their needs, highlighting the urgent need for further research (\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The participation of women in competitive sports continues to grow, so does the number of elite athletes who become pregnant. According to the Patient Rights Act, they have a right to comprehensive and evidence-based health information (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, the evidence base for the current recommendations appears insufficient. Therefore, a fundamental step is to gain a deeper understanding of pregnancy-related changes in musculoskeletal and functional characteristics, to improve and strengthen evidence-based information on safe and healthy exercise during pregnancy.\u003c/p\u003e\u003cp\u003eThe psychological implications of pregnancy and motherhood for elite athletes are significant, beyond the physical aspects. The transition to motherhood can provoke heightened stress and anxiety, as well as shifts in identity, particularly in relation to athletic performance and career expectations (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). It is crucial to address these psychological dimensions in order to develop multidisciplinary support systems that enable a balanced transition without compromising athletic careers (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eReturning to elite performance after childbirth presents further challenges, including physical recovery, managing mental health, and navigating new social dynamics (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). It is essential to understand these complex transitions in order to devise strategies that support elite athletes in regaining competitive form while managing the demands of motherhood.\u003c/p\u003e\u003cp\u003eThis scoping review systematically maps the current evidence on training, performance, physical health (including birth outcomes), and psychological aspects among elite female athletes throughout the pre-, peri-, and post-pregnancy periods. Unlike previous reviews, this review adopts a focused inclusion strategy that considers all types of original research and review articles involving elite athletes classified as tier 3 to tier 5 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This narrow focus enables a more precise understanding of this specific and understudied population. In doing so, the review not only incorporates newly published studies (up to 2025) that were not addressed in earlier syntheses, while also identifying relevant evidence that was previously overlooked. By applying rigorous and clearly defined eligibility criteria, this review provides a robust, targeted evidence base for aspects of training, performance, physical health, and psychological aspects throughout the entire continuum of pre-, peri- and postnatal stages. Our aim is to highlight persistent research gaps to inform future empirical studies.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis scoping review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines (15). The review protocol was registered with the PROSPERO database (CRD420250651470). Figure 1 presents the flow chart of the study selection process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe eligibility criteria for the literature included in this review were guided by the CoCoPopS framework (16)to identify appropriate studies. \u003cstrong\u003ePopulation\u003c/strong\u003e. The population of interest was elite female athletes \u0026nbsp;classified as tiers 3-5 (14), who were highly trained and performed at a world-class level, with a minimum of eight hours of training per week. Athletes who appeared to belong to tier 3, but were not explicitly assigned to a classification in the article, were categorized based on other indicators (Appendix A1) and labeled with an asterisk (*). Inconclusive study groups comprising a significant proportion of elite female athletes identified by terms such as \u0026ldquo;competitive\u0026rdquo; or \u0026ldquo;professional\u0026rdquo; were also included in the analysis and labeled as a \u003cem\u003emixed group\u003c/em\u003e. \u003cstrong\u003eCondition.\u003c/strong\u003e The review focuses on the training of elite athletes before, during, and after pregnancy. The focus is on understanding the key factors athletes need to consider when becoming pregnant, training during pregnancy without endangering themselves or their unborn child, and returning to their optimal performance level after childbirth. These factors include training, performance, physical health, and psychological aspects. \u003cstrong\u003eContext.\u003c/strong\u003e Studies were eligible for inclusion if they reported on elite athletes at any point during pregnancy, and if the athletes were active in a high-performance sports environment at this time. \u003cstrong\u003eStudy.\u003c/strong\u003e To capture all relevant original studies, reports, and reviews on the topic, primary research studies were eligible for inclusion, irrespective of their design. The focus was placed on original studies, encompassing randomized controlled trials, controlled trials, single-case, observational studies, and qualitative studies. Reviews, overviews and books or book chapters were also included to identify original studies that might have been overlooked during the initial search.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSearch Strategy and Study Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo address the review questions, a preliminary search was conducted in January (2025), without restricting the year of publication. A structured search was then carried out across multiple electronic databases, including PubMed, MEDLINE, Cochrane, Web of Science, Scopus, PsycNet, EMBASE, PsycINFO, Sponet, and Surf. A sensitive search strategy was applied, incorporating free text terms pertinent to the research, and, where possible, focusing on titles and abstracts related to elite athletes and pregnancy. The full search strategy is detailed in Appendix (A2).\u003c/p\u003e\n\u003cp\u003eThe study selection process involved two independent raters (IT and JN), who screened the titles and abstracts of the identified studies to determine their relevance. In cases of uncertainty, the full text of the articles was retrieved for further evaluation. In the second step, the same raters assessed the full-text articles independently for final inclusion. Any discrepancies were resolved through discussion or by consulting a third or fourth reviewer (PP or KL). Additional articles were retrieved from the reference lists of included studies where applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Figure 1 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Extraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFormal data extraction was performed for all the original articles included in the study (Table 1). Two raters (IT and JN) extracted the relevant data independently. The following data were extracted: author, year of publication, study design, population, context, condition, level of evidence, comparison, and outcome, along with the major findings. To provide a comprehensive understanding of the experience of elite athletes, the results were organized within a temporal framework comprising three main phases: before pregnancy, during pregnancy, and after pregnancy. Within each phase, the findings were categorized thematically into four domains: training, performance, physical health, and psychological aspects. Further, the findings on birth outcomes were summarized. The main outcomes were training and performance parameters, competitions, maternal and fetal heart rate, body weight, complications, symptoms, injuries, return to sport and competition, breastfeeding, fertility, safety concerns, advice, anxiety, and identity. If available, birth outcomes were documented as follows: birth weight, birth mode, onset of labor, length of labor, Apgar score, and complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Table \u0026ldquo;Data extraction\u0026rdquo; here\u003c/strong\u003e\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eCurrent State of Literature\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn recent years, there has been a significant increase in the number of publications addressing pregnancy in elite athletes. A particular rise has been observed over the last two decades, with 16 studies being published in the last five years alone (compared to nine studies between 1970 and 1999, and 22 studies between 2000 and 2019).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristics of Included Studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing a comprehensive search across multiple databases and citation tracking, a total of 5,236 records were identified (Figure 1). After removing duplicates, 3,927 articles underwent title and abstract screening. Of these, 3,623 were excluded based on predefined criteria. Full texts of 302 articles were assessed for eligibility, resulting in the exclusion of 200 studies due to reasons such as absence of focus on pregnancy, lack of elite athlete populations, policy-focused content, duplicate publication, or missing full-text availability (not even in the largest medical library in Germany, the Central Medical Library in Cologne).\u003c/p\u003e\n\u003cp\u003eUltimately, 102 studies were included in the scoping review. Of these, 55 were categorized as review or overview articles (Appendix A3), while the remaining 47 were original research articles that underwent detailed data extraction. Compared to the last available scoping review (17), which included only 16 original studies, this review identified and extracted a total of 47 original studies for inclusion in the dataset. Further, compared to another review (18), which also incorporated all available literature (including reviews and mixed methods) and comprised 40 studies in total, this scoping review\u0026apos;s search strategy yielded 102 studies related to the topic of pregnancy and elite sport.\u003c/p\u003e\n\u003cp\u003eThe extracted original studies comprised various designs: six were experimental studies, eight were cross-sectional studies, seven were observational cohort studies, four were case\u0026ndash;control studies, nine were case reports or series, and 13 were qualitative studies. Six of the 47 studies were dataset duplicates, which were included in the data extraction due to different research questions or selection parameters.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMapping of Key Outcome Parameters\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrequency analysis illustrates the distribution of outcome parameters such as training, performance, physical health, and psychological aspects before, during, and after pregnancy, as well as birth outcomes in relation to study design and sample size (Figure 2). It is evident that there is a paucity of experimental studies (n=5), and, among these, a particular absence of randomised controlled trials (n=0). Furthermore, most cross-sectional and cohort studies are retrospective, which fundamentally reduces the strength of the overall evidence. A total of five experimental studies, eight cross-sectional studies, seven cohort studies, four case\u0026ndash;control studies, nine case reports or series, and 12 qualitative studies were included in the frequency analysis. One experimental study and one qualitative study were excluded due to duplication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Figure 2 A and B here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBefore Pregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTraining\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eElite athletes often become pregnant while still training with high volumes and intensities, and typically maintaining their usual training routines until the pregnancy is confirmed (9). Several studies indicate that women engage in 5 to 16 hours of training per week prior to conception (9,19,20). In specific disciplines such as running or judo, some athletes (24-57%) intentionally reduced training intensity or volume to support fertility or to align conception with planned career transitions (12,21,22).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePerformance\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeven out of eight Olympic-level athletes typically planned their pregnancies to avoid disrupting their peak performance periods (12,23). Some athletes used the time during pregnancy to rest and recover from injuries (12).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhysical Health\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost athletes who engage in elite training prior to pregnancy do not appear to experience negative effects on fertility or pregnancy outcomes (9,23,24). However, 23% of endurance athletes have reported irregular menstrual cycles or amenorrhea, alongside concerns about previous miscarriages potentially being linked to high training volumes (25). For elite athletes, planning for pregnancy can be particularly challenging, as they must balance reducing training to optimize fertility with maintaining competitive performance (22). Overall, athletes are generally found to be healthier than non-athletic controls, displaying higher levels of education and lower rates of smoking and chronic health conditions (26).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePsychological Aspects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe psychological burden of planning a pregnancy while pursuing an elite sport career can be significant. Many athletes reported being afraid of losing their team positions or sponsorships if they disclosed their pregnancies (22). The social pressure to choose between motherhood and athletic ambition can lead to significant internal and external conflict (22,27). Peer support and sharing experiences with other athlete-mothers emerged as essential sources of reassurance and emotional resilience (20).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDuring Pregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTraining\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross the studies, the majority of elite athletes continued to train during pregnancy. Training volume and intensity generally remained stable during the first trimester, but decreased gradually as the pregnancy progressed, particularly in the third trimester\u0026nbsp;(9,21,28\u0026ndash;31). While sport-specific training usually decreased, non-specific training, such as cycling, walking, cross training, and strength training, increased (Figure 3). Training typically shifts towards lower-intensity, non-contact activities such as swimming, walking, and cycling. High-intensity or sport-specific activities, such as jumping and contact sports like judo or netball, were often stopped due to safety concerns or physical changes (20,30,31).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Figure 3 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral studies have investigated heart rate thresholds that are considered safe for training during pregnancy among elite athletes. In one study, \u0026nbsp;a conservative threshold of \u0026lt;140 beats per minute was adopted by 42% of participants (28), though 39% preferred subjective measures, such as perceived exertion, to a fixed upper limit of heart rate during exercise. More detailed physiological assessments suggest that training within 50\u0026ndash;75% of heart rate reserve is generally safe, with no adverse fetal outcomes reported (32). One study examined the effects of strenuous treadmill exercise at 60\u0026ndash;90% maximum oxygen uptake (V̇O\u003csub\u003e2max\u003c/sub\u003e) during the second trimester (23\u0026ndash;29 weeks of gestation). The study found that fetal heart rate remains within normal limits when the maternal heart rate stays below 90% of its maximum. However, exercise exceeding this threshold led to reduced arterial uterine blood flow and transient fetal bradycardia, which resolved post-exercise. This indicates that the maternal heart rate should remain below 90% of its maximum to minimize potential fetal compromise (33). In addition, another study showed that transient fetal heart rate decelerations and elevated umbilical and uterine Doppler indices occurred in five highly active pregnant women subsequent to strenuous treadmill exercise. However, no enduring impairment of fetal well-being was observed (34).\u003c/p\u003e\n\u003cp\u003eThere is also evidence of longitudinal cardiovascular adaptations during pregnancy, including increased maternal heart rates during rest and submaximal exercise (35\u0026ndash;37). These findings suggest that pregnancy increases cardiovascular load even at submaximal intensities, highlighting the importance of personalized monitoring despite the lack of clearly defined heart rate thresholds. A considerable number of athletes have reported a preference for subjective metrics, such as perceived exertion, or \u0026ldquo;listening to the body\u0026rdquo; approaches. These strategies are frequently described as \u0026ldquo;go with the flow\u0026rdquo; approaches (20,28,30,38).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompared to the year prior to pregnancy, athletes do not reduce their weekly duration of low-intensity training during the first trimester compared to the year prior to pregnancy (452 \u0026plusmn; 300 minutes per week) (30). Most athletes stopped competing after the first trimester, citing physical changes and risk aversion as the main reasons (20,25,30). Several studies indicate that elite athletes continued strength and core training during pregnancy, often modifying their training to accommodate physiological changes and mitigate injury risk. Training typically focused on the pelvic floor, abdominal and lower limb muscles, particularly in the later stages of pregnancy, to prevent dysfunction (30,39,40). Athletes tended to choose low-risk activities such as swimming, cycling, and stabilization exercises while avoiding high-impact or abdominally stressful movements (20). However, a lack of evidence-based guidance on strength training during pregnancy is frequently reported, leading many athletes to rely on peer networks or self-directed adaptations (9,29). More broadly, athletes consistently cite peer support or personal experience as their primary source of guidance, due to the ongoing absence of expert advice tailored specifically to elite performance contexts (22,29).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePerformance\u003c/em\u003e\u003cbr\u003e Some studies have examined the impact of pregnancy on athletic performance. These studies have observed increased cardiovascular responses, including elevated resting heart rate and reduced V̇O\u003csub\u003e2max\u003c/sub\u003e, while submaximal performance capacity has remained largely stable\u0026nbsp;(35,37). Another study demonstrated that\u0026nbsp;V̇O\u003csub\u003e2max\u003c/sub\u003e remains stable during endurance testing in pregnancy, while resting oxygen uptake increases, maximum carbon dioxide production decreases and hyperventilation persists. A slight reduction in maximum heart rate was also observed (42). \u0026nbsp;A study comparing high- and medium-volume exercise groups during pregnancy found no significant differences in skinfold thickness, blood values, or perceived exertion. However, maternal resting heart rate increased during pregnancy, and only the high-volume group showed an improvement in oxygen consumption at maximal load. This finding suggests that, despite variing baseline capacities, there is comparable overall response to exercise (19).\u003c/p\u003e\n\u003cp\u003eWhile many elite athletes continued to participate in competitions during the first trimester of pregnancy, the majority subsequently reduced or ceased competitive activity from the second trimester onward\u0026nbsp;(25,29,30,39). While performance-focused training was generally avoided during this period, some athletes continued to engage in technical skill and strength training (30,40,43).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhysical Health\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe health effects of high-performance training during pregnancy are still being debated. However, the majority of studies suggest that moderate-intensity exercise does not have a negative impact on maternal or fetal health (19,25,32). Although physiological adaptations such as an elevated maternal heart rate and slower core temperature recovery post-exercise have been documented, peak temperatures have remained within safe limits (44). While moderate-intensity exercise is generally well tolerated, high-intensity training exceeding 90% of the maximum heart rate (33) and repeated sprint efforts (36) were identified as critical thresholds. Transient fetal bradycardia was observed in these instances.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSerious complications are rare, with only a few cases of mild pre-eclampsia, obstetric cholestasis, altered liver enzymes, and HELLP syndrome reported. None of these were conclusively linked to physical activity (33,37,45). Other reported complications include general pregnancy disturbances (30%) (23), anemia (27%), and miscarriage or preterm birth (10.7%). However, no significant differences were found between athletes and controls (46). One study found that 23% of participants had previously experienced a spontaneous abortion, with five participants attributing this to intense training (25).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCommon symptoms during pregnancy include back pain, fatigue, nausea, dizziness, \u0026nbsp; urinary incontinence, and musculoskeletal discomfort, particularly in the third trimester (20,29,36). However, elite athletes reported similar or even fewer pregnancy-related complaints compared to the control groups (9,43). Although the overall injury incidence is low, individual cases of stress fractures, ankle sprains, and muscle strains have been documented (9). Notably, a study revealed that 98.2% of athletes in one cohort reported no injuries during pregnancy (39).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe average gestational weight gain among elite athletes is between 9 and 14 kg. Those engaged in high-level competition are more likely to exceed the Institute of Medicine\u0026apos;s (IOM) recommendations slightly (13.7-16.1 kg) (39,47).\u003c/p\u003e\n\u003cp\u003eNotably, the majority of athletes (96%) reported an overall uncomplicated pregnancy experience with few or no significant symptoms\u0026nbsp;(39).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePsychological Aspects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePsychologically, pregnancy is a time of heightened uncertainty and emotional ambivalence for elite athletes. Many reported increased anxiety due to a lack of evidence-based guidance on safe training, coupled with fears that continued physical activity might affect fertility or the health of the fetus (22,29,48). The social and institutional pressure to choose between elite sport and motherhood intensifies this emotional strain further, contributing to conflicts of identity and concerns about career security (22,27,49,50). Pregnancy is often treated like an \u0026ldquo;injury,\u0026rdquo; meaning athletes receive no pay if they are not competing, which in turn pressures them to continue training or return to competition during pregnancy or shortly after giving birth (50). Athletes often struggle with changes in body image and self-perception, as well as fears of a decline of performance (22,48). However, studies also highlight the potential benefits of psychopedagogical interventions, such as relaxation training and counseling, which can \u0026nbsp;significantly reduce anxiety and depressive symptoms during pregnancy (41).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite these psychological challenges, some athletes reported positive emotional engagement with their changing bodies, describing pregnancy as a time of physical and mental renewal (12). Notably, peer support and shared experiences with other athlete mothers emerge as crucial sources of reassurance, motivation, and resilience throughout the pregnancy journey (20).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAfter Pregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTraining\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe time it takes to return to training after childbirth varies from person to person, but it often happens earlier than the return to recreational sports in the general population. Many athletes resumed light activities, such as pelvic floor exercises, walking, or functional workouts, within the first six weeks after childbirth (9,20,40). Most elite athletes resumed training within 6\u0026ndash;12 weeks postpartum (9,21,30). More intense sessions typically follow after 8-12 weeks. 80% of pre-pregnancy training load was typically achieved within 14 \u0026plusmn; 11 weeks (21). The pre-pregnancy training volume was usually achieved within 3-9 months (23,30,39). The time taken to return to training after a cesarean birth varies (30,46). Studies also report coordination difficulties due to sleep deprivation and breastfeeding, which \u0026nbsp;impacts training (21,51). Darroch et al. (2023) observed that those who maintained higher training volumes in the first and second trimesters had better postnatal performance outcomes \u0026nbsp;(21).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePerformance\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe postpartum period is accompanied by the following physiological changes: a decrease in maternal heart rate, an increase in blood lactate concentrations, an early peak in oxygen uptake, and a slight reduction in vital capacity\u0026nbsp;(35). Many athletes successfully returned to their peak athletic performance, albeit at different speeds. Studies have shown that athletes can regain their pre-pregnancy performance levels\u0026nbsp;(23,38,39)\u0026nbsp;or even achieve personal bests\u0026nbsp;(21,28,36,52). One study found that 11% of athletes improved, 61% returned to the same level of performance, and 28% did not return to their previous level of performance after pregnancy\u0026nbsp;(25). In another study, 44% of athletes indicated that they had returned to the same level of performance, 15% reported an improvement in performance, while 26% exhibited a deterioration, and 15% were unsure\u0026nbsp;(9). The rate of recovery is significantly influenced by several factors, including the duration of breastfeeding, the volume of training during pregnancy and the postpartum period, and individual characteristics\u0026nbsp;(21). Additionally, the ability to return to sport and improve performance primarily depends on the age at which the athletes become pregnant, relative to their respective peak performance ages\u0026nbsp;(52). Postpartum sprint intervals or targeted endurance training have been shown to rapidly restore cardiovascular markers\u0026nbsp;(53,54).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhysical Health\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTypical postpartum health issues affect the musculoskeletal system, causing problems such as pelvic floor weakness, rectus diastasis, and stress fractures, as well as back pain and incontinence\u0026nbsp;(12,46,55). Despite these challenges, many athletes reported a stable recovery and return to normal physical performance within a year\u0026nbsp;(9,56). Breastfeeding, although logistically demanding, is often continued alongside training; however, potential impacts on performance may arise from sleep disruption or challenges related to milk supply. At this stage, it is crucial to ensure that athletes are drinking enough fluids\u0026nbsp;(11,51)\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePsychological Health\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe psychological outcomes in the studies are mixed: female athletes reported newly gained strength and determination as a result of motherhood. However, they also report feelings of insecurity, excessive demands, and depressive symptoms, particularly due to social expectations and the tension between career and motherhood (11,55,57). Motherhood was reported to be perceived as a transformative experience (58). Athletes reported improved life balance, increased motivation, and a redefined athletic identity (38,57). Emotional struggles includ feelings of guilt, pressure, and difficulties to return to sport, loss of squad status and difficulty reconciling changes to the body with athletic goals (11,49,55). Emotional and mental support from the immediate environment was specified as a key resource (49). The identity of being both \u0026ldquo;athlete\u0026rdquo; and \u0026ldquo;mother\u0026rdquo; was often redefined and served as a source of motivation and inspiration (50,57). However, a lack of professional psychosocial support remains a significant issue (58,59).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBirth Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe birth outcomes of elite athletes appear to be largely comparable to, or even slightly better than, those of the general population. Several studies reported high rates of spontaneous vaginal delivery (~70%) (Figure 4) and healthy Apgar scores after five minutes (\u0026gt;7), with no differences observed compared to controls (32,39,46). Cesarean section rates vary, but are not elevated in most elite cohorts compared to controls (24,39,60).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Figure 4 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImportantly, no consistent negative effects of intense or sustained training on labor or neonatal outcomes have been demonstrated. Studies comparing elite athletes to non-athletes showed no significant differences in birth mode, duration of labor, need for interventions, complications or neonatal health metrics (23,25,60,61). However, some data suggest an increased likelihood of prolonged labor among highly trained women, potentially due to stronger pelvic musculature (23).\u003c/p\u003e\n\u003cp\u003eBirth weight generally falls within normal ranges, with an average value of 3.403 \u0026plusmn; 487 grams (Figure 5). However, contradictory findings have been reported in the literature. Some studies reported slightly higher weights in conjunction with increased maternal exercise intensity (28), while others reported lower weights in endurance athletes with high training volume (33). Perineal injuries and interventions (e.g., episiotomies) were reported in line with general trends and were not consistently correlated with athletic status (24,60).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Figure 5 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, the available evidence supports the idea that participation in elite-level sports during pregnancy is not associated with adverse birth outcomes, provided that training intensity and volume is appropriately moderated and medical supervision is in place.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis review provides a unique, comprehensive, and up-to-date overview of the current state of research on pregnancy and elite sports. By systematically searching 10 different databases, a more extensive array of original articles has been included than in any previous review on the topic. Furthermore, it identifies and discusses existing research gaps with the aim of fostering systematic development in original experimental research studies.\u003c/p\u003e\n\u003cp\u003eThis work reveals the growing prominence of pregnancy in elite sports, while also highlighting significant gaps that hinder the development of concrete, evidence-based guidelines. Notably, much of the current literature is predicated on a limited number of original studies, emcompassing limited sample sizes, single-case reports, or retrospective designs. This severely restricts the ability to generalize, particularly with regard to fertility, training load, intensity thresholds during pregnancy, and the timing of the postpartum return to sport.\u003c/p\u003e\n\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\n \u003ch2\u003eFertility\u003c/h2\u003e\n \u003cp\u003eThere are inconclusive findings regarding the impact of elite sports on female fertility. In general, athletes with a mean training volume of around 15 hours per week can maintain their training load when the energy status is balanced and when planning to conceive without severe reproductive consequences (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). However, the combination of high-performance training and the Relative Energy Deficiency Syndrome in Sports (REDs) has been shown to result in a deterioration of reproductive function, independent of total weekly training hours (\u003cspan class=\"CitationRef\"\u003e62\u003c/span\u003e). The majority of studies have exclusively included female athletes who have experienced successful pregnancy. A high number of unreported cases of fertility disorders may exist among athletes who were not examined within the scope of these studies.\u003c/p\u003e\n \u003cp\u003eMoreover, miscarriages may be substantially underreported among elite athletes, partly due to social stigma and a paucity of open discussion (\u003cspan class=\"CitationRef\"\u003e63\u003c/span\u003e). Therefore, it is necessary to systematically compile and analyze medical data on this population to comprehensively understand the extent of the reproductive health risks and outcomes faced by highly trained female athletes.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eTraining load\u003c/h3\u003e\n\u003cp\u003eThe ongoing reliance on subjective metrics, including perceived exertion and self-monitoring, underscores a notable absence of standardized physiological benchmarks (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e). Recommendations on maternal heart rate during pregnancy, for example, are predominantly derived from single experimental studies (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) and cannot yet serve as robust guidelines. Similarly, the hypothesis that training below 90% of maximum heart rate (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) or within 50\u0026ndash;75% of heart rate reserve (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) is \u0026ldquo;safe\u0026rdquo; is not supported by high-level evidence. This hypothesis requires replication and confirmation through larger controlled trials. The absence of standardized, sport-specific recommendations means that athletes depend significantly on self-monitoring and peer advice (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). While this strategy emphasizes physical autonomy, it can also expose athletes to the risks of overtraining, injury, and inadequate postpartum recovery. In our view, the assertion that moderate exercise intensity can be gauged by the ability to still speak during exercise (the \u0026ldquo;talk test\u0026rdquo;) or by means of perceived exertion scales (\u003cspan class=\"CitationRef\"\u003e64\u003c/span\u003e) is inadequate for evidence-based recommendations concerning training management.\u003c/p\u003e\n\u003cp\u003eWith respect to the management of training loads, the data indicates that elite athletes adjust their training volume, intensity, and type during pregnancy. However, the optimal \u0026ldquo;safe\u0026rdquo; ranges remain unresolved. Furthermore, a systematic comparison with general recommendations for recreationally active pregnant women has not been undertaken (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). The systematic documentation of weekly training loads, as referenced in studies (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e), is needed. The development of single sport-specific recommendations on training adjustments during pregnancy appears to be an unrealistic objective at this time. Consequently, further research is necessary into specific sports groups, including endurance sports, team sports, high-impact sports, and explosive strength sports.\u003c/p\u003e\n\u003cp\u003eIdeally, phase-specific documentation of training and health data should be organized according to gestational age in weeks, or at least in trimesters, to help move beyond inconsistent descriptive data and derive general recommendations. Recommendations regarding resistance training during pregnancy are neither uniform nor consistently evidence-based. Thus, the question remains as to how muscle strength and muscle tone, particularly that of the pelvic floor, influence the course of labor and delivery (\u003cspan class=\"CitationRef\"\u003e65\u003c/span\u003e). For instance, it is unclear whether strengthening the already strong pelvic floor of elite athletes would have a positive or negative impact on the progression of childbirth.\u003c/p\u003e\n\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\n \u003ch2\u003eReturn to sport\u003c/h2\u003e\n \u003cp\u003ePostpartum return to sport patterns are highly individualized. While many athletes successfully return to or surpass pre-pregnancy levels of training loads and performance (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e), this process is influenced by factors, such as breastfeeding, sleep deprivation, injury history, and psychosocial support (\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e). However, the current evidence base is largely comprised of self-reported retrospective outcomes, which introduces the potential for bias that could mask underlying vulnerabilities, particularly with regard to pelvic floor health or injury recurrence (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e). Interestingly, athletes often report fewer common pregnancy-related issues than recreationally active women, potentially due to superior baseline fitness and body awareness (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). Nevertheless, clear medical guidance on sport-type-specific risks and considerations is lacking and urgently needed, particularly in disciplines where body mass plays a crucial role (e.g., aesthetic or weight-class sports) or where strong abdominal muscles are essential, especially with regard to injury prevention and pelvic floor health.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\n \u003ch2\u003ePsycological dimensions\u003c/h2\u003e\n \u003cp\u003eIn terms of psychological aspects, motherhood can be a source of both empowerment and significant stress (\u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e59\u003c/span\u003e). Identity conflicts, social pressures, and sponsorship concerns can exacerbate these challenges (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). Data suggest that successful return to sport depends on physical readiness as well as psychosocial, logistical, and financial support systems. Having individualized recovery plans that set out the competencies to be achieved during the postpartum period, alongside a structured reintegration into competition, could reduce risks, and support sustainable performance improvements. While there is some evidence to suggest psychological benefits, such as enhanced resilience (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e), the formal evaluation of mental health interventions using standardized tools, such as validated questionnaires, remains rare (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\n \u003ch2\u003eBirth outcomes\u003c/h2\u003e\n \u003cp\u003eFinally, the birth outcomes of elite athletes seem to be largely similar to those of the general population (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e). However, it should be noted that these findings are based on small, heterogeneous samples, so they should be interpreted with caution. Observations regarding prolonged labor or slight deviations in neonatal weight suggest potential physiological adaptations (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e). Nevertheless, further systematic research specific to different sports is essential before definitive conclusions can be drawn.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\n \u003ch2\u003eResearch Gaps and Future Directions\u003c/h2\u003e\n \u003cp\u003eIn light of these gained insights, future research should prioritize high-quality experimental and prospective studies involving larger and more diverse cohorts of athletes. Interventions combining individualized training prescriptions, standardized physiological monitoring, and comprehensive psychosocial support should be systematically developed and evaluated. Furthermore, long-term follow-up is necessary to assess sustained health and performance trajectories, as well as immediate postpartum outcomes.\u003c/p\u003e\n \u003cp\u003eThe present review emphasizes the necessity of systematic, in-depth descriptive documentation, and the advancement of more mechanistic and interventional research. Closing these evidence gaps is essential to developing meaningful, sports group-specific guidelines that go beyond anecdotal strategies and provide genuine support for athletes and mothers at the highest level.\u003c/p\u003e\n \u003cp\u003eNotwithstanding the mounting involvemen of women in high-performance sports, the available evidence remains fragmented (Fig.\u0026nbsp;6). The majority of studies utilize retrospective designs, small sample sizes, and self-reported data. Notably, there is a lack of prospective, sports group-specific studies examining the physiological, psychological, and performance-related changes across the entire peri-pregnancy timeline. A paucity of studies exists that provide structured, evidence-based return to sport protocols, and even fewer address the long-term career trajectories of athlete mothers. Furthermore, psychological dimensions such as identity negotiation, postpartum mental health, and societal expectations are underrepresented in quantitative research. The current literature also favors endurance sports in Western contexts and offers limited insights into team sports, weight-class sports, or para-sport disciplines. Addressing these disparities is imperative for the development of effective, personalized support systems and policies that reflect the realities of elite sport and motherhood.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInsert Fig. 6 here\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLongitudinal, prospective studies with larger sample sizes are urgently needed to generate robust data that can inform policy, medical practice, and coaching strategies. The extant body of research is predominantly composed of retrospective, qualitative, or single-case studies. However, the dearth of studies employing longitudinal, controlled, or interventional designs, compromises the extent to which robust conclusions can be drawn. Additionally, the absence of standardized outcome measures across studies complicates the synthesis and comparison of findings, impeding the establishment of clear conclusions.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis scoping review underscores the intricate interplay of physiological, psychological, and social factors that influence the experiences of elite female athletes during pregnancy and the postpartum period. Despite the increasing recognition of the advantages of continuing to train during pregnancy, elite athletes are still not receiving the evidence-based, sport group-specific guidelines they need to address their unique requirements and performance objectives. The extant literature underscores the remarkable physical adaptability of athlete-mothers and their promising return to performance trajectories. However, these positive outcomes are frequently attained in the absence of standardized medical and coaching frameworks, thereby exposing athletes to potential risks, particularly relating to injury and inadequate postpartum recovery.\u003c/p\u003e\u003cp\u003eFurthermore, the transition to motherhood constitutes a substantial psychological and social transformation. While this phenomenon may be empowering for some, it concomitantly engenders significant emotional challenges. The dual identity of athlete and mother has been demonstrated to be a source of resilience and renewed motivation. However, there is a clear need for targeted mental health support and integrated psychosocial interventions.\u003c/p\u003e\u003cp\u003eThis review uncovers significant gaps in the current evidence base, particularly with regard to prospective, sport group-specific research across diverse athletic disciplines and cultural contexts. There is an urgent need for longitudinal studies that employ standardized outcome measures. These studies are necessary to inform the development of tailored training adaptations, return to sport protocols, and multidisciplinary support strategies. Addressing these disparities is imperative for developing comprehensive, personalized guidelines that facilitate the safe and sustainable pursuit of athletic excellence by elite athletes while ensuring the optimal conditions for motherhood.\u003c/p\u003e\u003cp\u003eIn order to accomplish the aforementioned research objectives, it is imperative to establish an international collaborative research network. This network will assure that sample sizes are sufficiently large and diverse across sports, regions, and performance levels.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eV̇O\u003csub\u003e2max\u003c/sub\u003e: Maximum oxygen uptake \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the responsible ethics committee, no formal ethics approval was required for this study, as it is based exclusively on the evaluation of data that are already publicly accessible and have been previously published in the scientific literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data analyzed during this scoping review are included in the published article, in the tables that summarize the included studies. The corresponding author can provide reasons for the exclusion of studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJana Nolte, Isabell Thal, Emily Büthe, Susanne Weber, Petra Platen and Kirsten Legerlotz declare that they have no competing interests relevant to the content of this review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was funded by the Federal Institute for Sports Science (BISp) based on a decision by the German Bundestag (ZMI4-080118/24).\u003c/p\u003e\n\u003cp\u003eRuhr University Bochum enabled Open Access funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: PP and KL; Search: JN and IT; Title, abstract and full text screening: JN and IT; Data extraction: JN and IT; Drafting: JN; Creation of figures and tables: JN; Critical review of the manuscript: IT, EB, SW, PP and KL. All authors read and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the collaborators (Katharina Fischer, Dr. Maren Goeckenjan, Prof. Dr. Christine Joisten, Prof. Dr. Karsten Köhler, Prof. Dr. Birgit Schulte-Frei, and Prof. Dr. Jana Strahler), the project advisory board (Prof. Dr. Ulrike Burrmann, Prof. Dr. Klara Brixius, Prof. Dr. Anja Carlsohn, Dr. Sabrina Forster, Dr. Nina Kimmich, Dr. Karsten Königstein, Prof. Dr. Franziska Lautenbach, and Prof. Dr. Hans Trampisch), and the representatives of the BISp (Dr. Andrea Horn and Daniela Fett) of the project \u003cem\u003ePregnancy and Elite Sport\u003c/em\u003e for their continuous support and active contribution.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNkhata LA. Exercise Practice Among Women Attending Antenatal Care at the University Teaching Hospital in Lusaka, Zambiaq. 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Verf\u0026uuml;gbar unter: https://ijspt.scholasticahq.com/article/65894-the-mother-load-and-return-to-sport-a-case-report-of-returning-to-professional-netball-following-cesarean-section\u003c/li\u003e\n\u003cli\u003eAppleby KM, Fisher LA. \u0026ldquo;Running in and out of Motherhood\u0026rdquo;: Elite Distance Runners\u0026rsquo; Experiences of Returning to Competition after Pregnancy. Women in Sport and Physical Activity Journal. April 2009;18(1):3\u0026ndash;17. \u003c/li\u003e\n\u003cli\u003eMartinez-Pascual B, Alvarez-Harris S, Fern\u0026aacute;ndez-De-Las-Pe\u0026ntilde;as C, Palacios-Ce\u0026ntilde;a D. Maternity in Spanish Elite Sportswomen: A Qualitative Study. Women \u0026amp; Health. 3. April 2014;54(3):262\u0026ndash;79. \u003c/li\u003e\n\u003cli\u003eMassey KL, Whitehead AE. Pregnancy and motherhood in elite sport: The longitudinal experiences of two elite athletes. Psychology of Sport and Exercise. 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Sport, exercise and the menstrual cycle: where is the research? Br J Sports Med. M\u0026auml;rz 2017;51(6):487\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003ePhysical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804. Obstetrics \u0026amp; Gynecology. April 2020;135(4):e178\u0026ndash;88. \u003c/li\u003e\n\u003cli\u003eDavenport MH, Ruchat SM, Sobierajski F, Poitras VJ, Gray CE, Yoo C, u. a. Impact of prenatal exercise on maternal harms, labour and delivery outcomes: a systematic review and meta-analysis. Br J Sports Med. Januar 2019;53(2):99\u0026ndash;107. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sports-medicine-open","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"smoa","sideBox":"Learn more about [Sports Medicine-Open](http://sportsmedicine-open.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/smoa/default.aspx","title":"Sports Medicine-Open","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"gestation, perinatal health, high-performance athletes, Olympic-level athletes,female research, hormones ","lastPublishedDoi":"10.21203/rs.3.rs-7764218/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7764218/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nThe number of elite female athletes navigating pregnancy continues to rise, yet the intersection of high-performance sport and motherhood remains understudied. This scoping review summarizes the literature on training, performance, physical health, and psychological aspects before, during, and after pregnancy in elite athletes (tiers 3–5). The aim is to identify knowledge gaps and to inform future research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nThis review was conducted in accordance with the PRISMA-ScR guidelines and was registered with PROSPERO (CRD420250651470). At 8\u003csup\u003eth\u003c/sup\u003e of January 2025, a systematic search of 10 databases (e.g., PubMed, Scopus, and PsycINFO) was conducted. Studies were eligible for inclusion if they involved elite female athletes during the pre-pregnancy, pregnancy, or postpartum phases. Data extraction included information on study design, athlete classification, training, health, performance, and psychological outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nOf the 5,236 records examined, 102 studies met the inclusion criteria and 47 original research articles underwent detailed data extraction. Elite athletes often plan their pregnancies very carefully. Although high-performance training combined with a healthy diet does not necessarily impair fertility, some athletes reduce their training to support their fertility. Furthermore, there is no evidence to suggest that high training loads have a negative impact on the course of pregnancy. Evidence shows that elite athletes typically continue to train throughout pregnancy, adjusting the load, and resume training early after childbirth. Although highly individualized, performance recovery is feasible. Moderate-intensity exercise appears to be safe, but thresholds above 90% of maximum heart rate may impact fetal responses. Psychological stress, identity conflicts, and a lack of tailored guidelines are common challenges. Most birth outcomes match or exceed those of the general population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003cbr\u003e\nDespite the emergence of new evidence, there are still significant gaps in the research regarding individualized training protocols, postpartum return to sport strategies, and mental health interventions for elite athletes peri- and post-pregnancy. The current literature favors endurance sports and Western populations, highlighting the need for more diverse, prospective, and interdisciplinary research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistration: \u003c/strong\u003eThe protocol for this review was registered in the PROSPERO database (CRD420250651470).\u003c/p\u003e","manuscriptTitle":"Elite Athletes and Pregnancy: Training, Performance, Health and Psychological Aspects Across Pre-, Peri-, and Postnatal Stages - A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 07:02:16","doi":"10.21203/rs.3.rs-7764218/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revision","date":"2025-11-27T22:20:14+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-10-15T12:19:40+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-14T23:04:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Sports Medicine-Open","date":"2025-10-13T22:33:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-08T12:19:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Sports Medicine-Open","date":"2025-10-07T09:11:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sports-medicine-open","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"smoa","sideBox":"Learn more about [Sports Medicine-Open](http://sportsmedicine-open.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/smoa/default.aspx","title":"Sports Medicine-Open","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c5116c16-fd1e-40e1-90ab-4c378692e2a3","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:01:00+00:00","versionOfRecord":{"articleIdentity":"rs-7764218","link":"https://doi.org/10.1186/s40798-026-01000-5","journal":{"identity":"sports-medicine-open","isVorOnly":false,"title":"Sports Medicine-Open"},"publishedOn":"2026-03-09 15:57:54","publishedOnDateReadable":"March 9th, 2026"},"versionCreatedAt":"2025-10-29 07:02:16","video":"","vorDoi":"10.1186/s40798-026-01000-5","vorDoiUrl":"https://doi.org/10.1186/s40798-026-01000-5","workflowStages":[]},"version":"v1","identity":"rs-7764218","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7764218","identity":"rs-7764218","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}