Background The 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 and sub-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 8th 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 highly (or more) trained 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 5236 records examined, 101 studies met the inclusion criteria and 46 original research articles underwent detailed data extraction. Elite and sub-elite athletes often plan their pregnancies very carefully. The available evidence does not clearly demonstrate negative effects of high training loads on pregnancy outcomes. However, the limited, often outdated, and predominantly endurance-focused data do not allow firm conclusions. Evidence shows that elite and sub-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 While no consistent evidence of adverse pregnancy outcomes from high training loads has been reported, the existing studies are too limited and heterogeneous to allow firm conclusions. These gaps, along with an evidence base largely derived from endurance-focused sports and Western populations, highlight the ongoing need for more diverse, contemporary, and sport-specific research on training, return-to-sport, and mental health in pregnant elite athletes. Registration The protocol for this review was registered in the PROSPERO database (CRD420250651470). Key points - 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.
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