Abstract: We included 11 randomised trials, involving 638 women. The overall risk of bias was judged to be unclear due to lack of methodological detail in the included studies. For the mother, there was no clear evidence of a difference between women in the exercise group and those in the control group for the risk of pre-eclampsia as the measure of hypertensive disorders of pregnancy (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.01 to 7.09; two RCTs, 48 women; low-quality evidence), birth by caesarean section (RR 0.86, 95% CI 0.63 to 1.16; five RCTs, 316 women; I2 = 0%; moderate-quality evidence), the risk of induction of labour (RR 1.38, 95% CI 0.71 to 2.68; one RCT, 40 women; low-quality evidence) or maternal body mass index at follow-up (postnatal weight retention or return to pre-pregnancy weight) (mean difference (MD) 0.11 kg/m2, 95% CI -1.04 to 1.26; three RCTs, 254 women; I2 = 0%; high-quality evidence). Development of type 2 diabetes, perineal trauma/tearing and postnatal depression were not reported as outcomes in the included studies. For the infant/child/adult, a single small (n = 19) trial reported no perinatal mortality (stillbirth and neonatal mortality) events in either the exercise intervention or control group (low-quality evidence). There was no clear evidence of a difference between groups for a mortality and morbidity composite (variously defined by trials, e.g. perinatal or infant death, shoulder dystocia, bone fracture or nerve palsy) (RR 0.56, 95% CI 0.12 to 2.61; two RCTs, 169 infants; I2 = 0%; moderate-quality evidence) or neonatal hypoglycaemia (RR 2.00, 95% CI 0.20 to 20.04; one RCT, 34 infants; low-quality evidence). None of the included trials pre-specified large-for-gestational age, adiposity (neonatal/infant, childhood or adulthood), diabetes (childhood or adulthood) or neurosensory disability (neonatal/infant) as trial outcomes. Other maternal outcomes of interest: exercise interventions were associated with both reduced fasting blood glucose concentrations (average standardised mean difference (SMD) -0.59, 95% CI -1.07 to -0.11; four RCTs, 363 women; I2 = 73%; T2 = 0.19) and a reduced postprandial blood glucose concentration compared with control interventions (average SMD -0.85, 95% CI -1.15 to -0.55; three RCTs, 344 women; I2 = 34%; T2 = 0.03). Short- and long-term outcomes of interest for this review were poorly reported. Current evidence is confounded by the large variety of exercise interventions. There was insufficient high-quality evidence to be able to determine any differences between exercise and control groups for our outcomes of interest. For the woman, both fasting and postprandial blood glucose concentrations were reduced compared with the control groups. There are currently insufficient data for us to determine if there are also benefits for the infant. The quality of the evidence in this review ranged from high to low quality and the main reason for downgrading was for risk of bias and imprecision (wide CIs, low event rates and small sample size). Development of type 2 diabetes, perineal trauma/tearing, postnatal depression, large-for-gestational age, adiposity (neonate/infant, childhood or adulthood), diabetes (childhood or adulthood) or neurosensory disability (neonate/infant) were not reported as outcomes in the included studies. Further research is required comparing different types of exercise interventions with control groups or with another exercise intervention that reports on both the short- and long-term outcomes (for both the mother and infant/child) as listed in this review.

Plain-language summary: We searched for evidence from randomised controlled trials in August 2016. We identified 11 trials that involved 638 pregnant women. They were conducted in middle-or high-income countries. We judged the overall risk of bias in the trials as unclear because of a lack of information about how the trials were conducted. Using GRADE, the quality of the evidence from the trials ranged from high to low quality. The main reasons for downgrading the quality were for risk of bias in the trials and imprecise effect sizes, low event rates and small numbers of participants. For the mothers, exercising did not appear to reduce the risk of pre-eclampsia as the measure of hypertensive disorders of pregnancy (two trials, 48 women, low-quality evidence), birth by caesarean section (five trials, 316 women, moderate-quality evidence), or the risk of induction of labour (one trial, 40 women, low-quality evidence). The mothers had similar body mass index at follow-up in the exercise and control groups (three trials, 254 women, high-quality evidence). Exercising was associated with lower fasting blood glucose levels (four trials) and blood glucose levels after a meal (three trials) but with variations in effect sizes between the different trials. The exercise programmes varied between trials as did their duration and whether or not they were supervised. None of the included trials reported on perineal trauma, postnatal depression or development of type 2 diabetes. For the babies, no deaths occurred around the time of birth in (one trial, 19 babies, low-quality evidence) and there was no evidence of any difference in the risk of ill-health (two trials, 169 babies, moderate-quality evidence) or low blood sugar levels (one trial, 34 babies, low-quality evidence). None of the trials reported on the number of large-for-gestational-age babies or babies that went on to develop diabetes in childhood or adulthood or neurosensory disability that became apparent during childhood. Although exercise appeared to be able to lower fasting blood sugar levels and sugar levels after a meal, we did not find any differences in other outcomes for pregnant women with GDM. The present evidence is insufficient to advise for or against women enrolling in exercise programmes. Even if exercise does not provide any benefit during pregnancy, this change in lifestyle may persist after birth and may help prevent the onset of type 2 diabetes and its long-term complications. Pregnant women with GDM who wish to enrol in an exercise programme may wish to discuss their choice with a health professional. Further research is needed comparing one exercise intervention with another (or with a control) and reporting on both the short- and long-term outcomes (for both the mother and infant/child/adult) as listed in this review.