Excessive daytime sleepiness in late pregnancy may not always be normal: results from a cross-sectional study

Sleep Disturbance in Pregnancy

Sleep is vital to life, even when women enter into pregnancy state. Good sleep is important for a healthy pregnancy. Sleep disturbances are common during pregnancy and can be due to the change of pregnancy itself or the results of sleep disorders. There is growing evidence linking sleep disturbances with adverse maternal and fetal outcomes. Differentiation of sleep disorders in order to provide appropriate treatment as well as promoting good sleep for pregnant women is important. A multidisciplinary team to provide sleep care during antenatal period may be needed.

Prediction Models of Obstructive Sleep Apnea in Pregnancy: A Systematic Review and Meta-Analysis of Model Performance

BACKGROUND

Gestational obstructive sleep apnea (OSA) is associated with adverse maternal and fetal outcomes. Timely diagnosis and treatment are crucial to improve pregnancy outcomes. Conventional OSA screening questionnaires are less accurate, and various prediction models have been studied specifically during pregnancy.

METHODS

A systematic review and meta-analysis were performed for multivariable prediction models of both development and validation involving diagnosis of OSA during pregnancy.

RESULTS

Of 1262 articles, only 6 studies (3713 participants) met the inclusion criteria and were included for review. All studies showed high risk of bias for the construct of models. The pooled C-statistics (95%CI) for development prediction models was 0.817 (0.783, 0850), I² = 97.81 and 0.855 (0.822, 0.887), I² = 98.06 for the first and second-third trimesters, respectively. Only multivariable apnea prediction (MVAP), and Facco models were externally validated with pooled C-statistics (95%CI) of 0.743 (0.688, 0.798), I² = 95.84, and 0.791 (0.767, 0.815), I² = 77.34, respectively. The most common predictors in the models were body mass index, age, and snoring, none included hypersomnolence.

CONCLUSIONS

Prediction models for gestational OSA showed good performance during early and late trimesters. A high level of heterogeneity and few external validations were found indicating limitation for generalizability and the need for further studies.

The impact of myo-inositol supplementation on sleep quality in pregnant women: a randomized, double-blind, placebo-controlled study

BACKGROUND

Myo-inositol, a glial marker which plays a critical role in some brain regions, can supposedly affect sleep processes. The purpose of randomized controlled trial was to evaluate the impact of myo-inositol supplementation on sleep quality of pregnant women.

METHODS

The study enrolled 60 women with low risk singleton pregnancies, with a gestational age of at least 14 weeks, in Iran. The participants were block randomized to receive myo-inositol supplementation powder containing 2000 mg of myo-inositol and 200 μg of folic acid or placebo (400 μg of folic acid) for 10 weeks from the gestational age of 14-24. Sleep quality was measured by the Pittsburgh Sleep Quality Index (PSQI). The primary outcome was the change in sleep quality from the first trimester to the second trimester (24-28 weeks). The ANCOVA with adjusted covariate variables in the first trimester was conducted to estimate the sleep quality between the two groups.

RESULTS

The results of ANCOVA boot strapped showed that the mean difference of the total sleep quality score between the two groups was -1.537; 95% CI: -3.050 to -0.024, p = .047) in the second trimester at immediately post-intervention. Also, there were significant differences between the two groups in terms of subjective sleep quality (MD: -0.427; 95% CI: -0.725 to -0.128, p = .006, sleep duration (MD: -0.670; 95% CI: -1.240 to -0.101; p = .022) and habitual sleep efficiency (MD: -0.561; 95% CI: -1.038 to -0.085, p = .022).

CONCLUSION

The research confirmed that myo-inositol supplementation can improve global sleep quality, subjective sleep quality, and sleep duration during pregnancy. Therefore, these findings applied to minimize the rate of poor sleep quality in pregnant women.

Symptoms of Daytime Sleepiness and Sleep Apnea among Pregnant Women

Objectives

Despite the fact that sleep disturbances have been associated with poor maternal and neonatal health outcomes in pregnancy, no studies have assessed excessive daytime sleepiness or the risk for sleep apnea among pregnant Saudi Arabian women. We sought to estimate the prevalence of excessive daytime sleepiness (EDS) and the high risk for sleep apnea (OSA) in a sample of pregnant Saudi women.

Methods

An anonymous self-report questionnaire was completed by 517 pregnant women who attended obstetric outpatient clinics at King Abdulaziz Medical City, Riyadh, Saudi Arabia, for a routine pregnancy check. We collected demographic and clinical data for all patients and used the Berlin Questionnaire and the Epworth Sleepiness Scale to determine the primary outcomes.

Results

A high risk of OSA was found in 37.1% of women (95% confidence interval (CI): 33.00%-41.50%), and EDS was found in 32.1% (95% CI: 28.10%-36.30%). The presence of both (EDS and a high risk of OSA) was found in 14.9% of women (95% CI: 11.90%-18.30%). We found increased odds of EDS in women who reported pain three times or more per week (adjusted odds ratio (aOR) = 2.59) and insomnia (aOR = 1.65). Older women (≥ 37 years) (aOR = 3.00), those who reported pain once a week (aOR = 1.99), pain twice a week (aOR = 2.75), three times or more a week (aOR = 2.57), and insomnia (aOR = 1.95) increased the odds of high risk for OSA.

Conclusions

EDS and a high risk for OSA affected a large portion of the pregnant women included in the study, primarily those who reported pain and insomnia. Our study provides important information for gynecologists to help promote healthy sleep and manage the issues arising from sleep disturbances among pregnant women as part of their daily practice.

Maternal sleep disordered breathing assessed by Epworth Sleepiness Scale and abnormal feto-placental Dopplers

Objective: Excessive daytime sleepiness is a frequently described phenomenon in pregnant women. The Epworth Sleepiness Scale (ESS) is a self reported standardized method of assessing sleep propensity and has been used extensively within pregnant populations. An elevated score is associated with sleep disordered breathing, as well as adverse obstetric and neonatal outcomes which may be indicative of a degree of placental dysfunction. Thus the aim of this study was to prospectively assess women using the Epworth questionnaire in conjunction with an ultrasound in both the second and third trimesters to determine if there was a difference in ESS scores across gestation and if a mid or late gestation assessment was correlated with Doppler ultrasound measures of fetal well-being.Materials and methods: Participants were prospectively recruited from a tertiary obstetric hospital and completed both an Epworth questionnaire and ultrasound examination in the second and third trimesters.Results: A total of 302 women took part in this cohort study. There was a statistically significant (p = .02) increase in ESS score across gestation. There was however no correlation identified in either the second or third trimester between ESS score and umbilical artery pulsatility index, middle cerebral artery pulsatility index, cerebroplacental ratio, umbilical venous flow, uterine artery pulsatility index or estimated fetal weight. A higher birth weight is associated with a higher ESS score in the second trimester but not in the third trimester (p = .03).Conclusions: Maternal sleep disordered breathing assessed by the ESS score is only correlated with increased birth weight but not with fetal Doppler parameters in low risk pregnancies.

Evaluation of Nocturnal Respiratory Complaints in Pregnant Women

Snoring during pregnancy increases the risk of low Apgar score and low birth weight of newborns. Snoring women are twice as likely to be diagnosed as having preeclampsia when compared to non-snoring ones. Snoring may also be linked to, albeit it is not a prerequisite for, apneic events at sleep. The aim of this survey-type study was to evaluate the occurrence and severity of nocturnal respiratory complaints in a group of 312 pregnant women. Problems associated with snoring and other nasopharyngeal symptoms were reported by 60% of women. Complaints were more frequent in patients with a higher body mass index. The symptoms were significantly more frequent in the group of snorers. The results of this study suggest a pattern of basic features in pregnancy, such as snoring, overweight, and upper airway symptoms, which all ought to direct attention of care givers to the diagnostics of sleep-related breathing disorders. The early diagnosis would enable to undertake the measures to prevent preterm labor and to avoid postpartum complications in both mother and newborn.

An Epworth Sleep Score ≥11 is associated with emergency operative birth and poor neonatal composite outcome at term

BACKGROUND

During pregnancy, the Epworth Sleepiness Scale can be used as a surrogate marker for maternal sleep-disordered breathing, a condition that is becoming increasingly prevalent in obstetric populations and is associated with a multitude of pregnancy complications.

AIMS

The aim of this observational study was to investigate the relationship between the Epworth Sleepiness Scale score and indication and mode of delivery during pregnancy.

MATERIALS AND METHODS

The Epworth Sleepiness Scale was completed by 178 women at Mater Mothers' Hospital, Brisbane, Australia.

RESULTS

Women with a score ≥11 were less likely to achieve a spontaneous vaginal delivery (aOR 0.43, 95% CI 0.21-0.88, P = 0.02), and were more likely to have an instrumental (aOR 2.81, 95% CI 1.30-6.08, P = 0.01) or any operative birth (instrumental and caesarean section aOR 2.32, 95% CI 1.14-4.71, P = 0.02). These women were also more likely to have an operative birth for intrapartum fetal compromise (aOR 2.62, 95% CI 1.21-5.69, P = 0.015), as well as an infant with poor neonatal outcomes (aOR 2.77, 95% CI 1.09-7.03, P = 0.03).

CONCLUSIONS

These results show that symptoms of sleep-disordered breathing are associated with emergency operative birth, particularly when the indication for operative birth was intrapartum fetal compromise.

Sleep Disturbances and Modulations in Inflammation: Implications for Pregnancy Health

When a woman becomes pregnant, there is a vast series of physiological, vascular, and psychological changes. Among the most commonly reported changes are those involving sleep. Pregnant women report that their ability to maintain sleep and acquire continuous refreshing sleep is impaired during the perinatal period as compared to the non-pregnant period. A growing literature supports the hypothesis that disturbed sleep (which comes in many forms) during the perinatal period is associated with an increased risk of adverse maternal, delivery, and infant outcomes. Among the suggested biological pathways linking sleep and adverse outcomes are disturbances in the immune and hormonal systems. The following paper will discuss (1) the various sleep processes that are commonly disturbed during the perinatal period and the methods used to collect sleep data; (2) the evidence linking sleep to adverse outcomes; and (3) how one specific biological pathway, the immune system, likely mediates these associations. The goal of this paper is to clarify the role that sleep disturbance has during pregnancy.

Pathophysiological changes associated with sleep disordered breathing and supine sleep position in pregnancy

Sleep is a complex and active physiological process that if disrupted, can result in adverse outcomes both within and outside of pregnancy. Sleep disordered breathing (SDB) occurs in 10-32% of pregnancies. Substantial physiological changes occur during pregnancy that impact on maternal sleep, which typically deteriorates with advancing gestation. Pregnancy challenges maternal homeostatic regulation of many systems which effect maternal sleep, including the respiratory, cardiovascular, endocrine, and immune systems. SDB can result from varying degrees of airway compromise and potentially cause systemic hypoxia. The hypoxia may be acute, intermittent or chronic in nature with complications dependant on the duration and the gestation at which the insult occurs. It is unlikely that this effect is mediated by a singular mechanistic pathway but results from a complex cascade of events across multiple maternal organ systems. Regardless of the etiology, both SDB and supine sleep position are associated with a variety of obstetric and perinatal complications including, pre-eclampsia/eclampsia, gestational diabetes mellitus, cardiomyopathy, heart failure, fetal growth restriction, poor neonatal condition at birth, stillbirth and neuro-psychiatric problems in offspring. Both maternal sleep position and sleep disordered breathing are potentially modifiable or treatable factors that if addressed have the potential to improve maternal and fetal outcomes. This narrative review summarizes the maternal and placental pathophysiological aberrations associated with sleep disordered breathing and supine sleep position in pregnancy.

The effect of relaxation exercises on sleep quality in pregnant women in the third trimester: A randomized controlled trial

OBJECTIVE

To assess the effects of relaxation exercises on subjective sleep quality of in third-trimester pregnant women.

MATERIALS AND METHODS

The pretest posttest randomized controlled trial recruited 84 pregnant women in the third trimester. Following random assignment of subjects, the treatment group (n = 46) performed relaxation exercises for four weeks and the control group (n = 46) received standart cares. At baseline and after the intervention sleep quality was assessed. Data obtained were analyzed in SPSS.

RESULTS

The mean score of the global Pittsburgh Sleep Quality Index was 7.12 ± 3.66. It was determined that relaxation exercises improved some sleep quality subscales including subjective sleep quality, sleep latency, sleep duration and habitual sleep efficiency, sleep disturbances, daytime dysfunction and global sleep quality. The difference between the two groups was found to be statistically significant (p < 0.05).

CONCLUSION

A four -week compact disc guide relaxation exercises program can be effective in improving sleep quality.

Diagnosis and treatment of obstructive sleep apnea during pregnancy

PURPOSE OF REVIEW

This review aims to provide an update on recent advances in the diagnosis and treatment of obstructive sleep apnea (OSA) during pregnancy and its effect on maternal and fetal outcomes.

RECENT FINDINGS

Current OSA screening tools may not perform well in this population. There are some pieces of evidence linking poorer maternal and neonatal outcome with pregnant patients having OSA. At present, there are inadequate data on which to base fetal or maternal parameters for treatment of OSA, and no evidence that treatment in the short-term impacts maternal or neonatal outcomes.

SUMMARY

Further research is needed to help in the detection and treatment of OSA in pregnancy.

Serum Progesterone Levels in Pregnant Women with Obstructive Sleep Apnea: A Case Control Study

BACKGROUND

Pregnancy is a risk factor for sleep disordered breathing, including obstructive sleep apnea (OSA). Progesterone, one of the key hormones in pregnancy, a known respiratory drive stimulant, increases ventilation and may protect against OSA. We aimed to examine the relationship between circulating progesterone and OSA, after accounting for body weight and gestational age.

METHODS

A case control study was conducted of pregnant women with OSA and those at low risk for the disorder. Cases were identified by ICD-9 code and review of medical record. Controls were identified if they scored zero (never) for snoring, apnea, and gasping on the multivariable apnea prediction index questionnaire immediately following delivery. Subjects with available stored first and/or second trimester residual serum samples were then included in this study and serum analyzed for progesterone. Raw progesterone levels were adjusted for the effects of gestational age and maternal weight.

RESULTS

Twenty-seven cases and 64 controls with available serum were identified. Women with OSA had greater maternal weight and higher rates of related comorbidities, compared to controls. Progesterone levels correlated positively with gestational age and negatively with greater weight. Progesterone levels, adjusted for gestational age and maternal weight and expressed as multiples of median (MoM), were significantly lower in OSA cases compared to controls in both the first trimester (MoM = 0.71, confidence interval [95% CI] 0.60-0.83) relative to the MoM in controls of 1.00. In the second trimester levels were also lower in OSA cases (MoM = 0.84, 95% CI 0.73-0.96) compared to the MoM of 1.00 in controls.

CONCLUSIONS

Progesterone levels, after accounting for weight and gestational age, were lower in women with OSA than controls. Progesterone may play a protective role against OSA.

Performance of screening questionnaires for obstructive sleep apnea during pregnancy: A systematic review and meta-analysis

This review aims to evaluate the performance of obstructive sleep apnea (OSA) screening questionnaires during pregnancy. A systematic review and meta-analysis was performed using MEDLINE Scopus, CINAHL, and the Cochrane library. A bivariate meta-analysis was applied for pooling of diagnostic parameters. Six of the total 4719 articles met the inclusion criteria. The Berlin questionnaire (BQ, N = 604) and Epworth sleepiness scale (ESS, N = 420) were the most frequently used screening tools during pregnancy. The pooled prevalence of OSA during pregnancy was 26.7% (95%CI: 16.9%, 34.4%, I² = 83.15%). BQ performance was poor to fair with pooled sensitivity and specificity of 0.66 (95%CI: 0.45, 0.83; I² = 78.65%) and 0.62 (95%CI: 0.48, 0.75; I² = 81.55%), respectively. BQ performance was heterogeneous depending on type of reference test and pregnancy. Sensitivity increased if diagnosis was based on polysomnography (0.90), and respiratory disturbance index (0.90). However, sensitivity decreased if screening was performed in early pregnancy (≤20 weeks gestation: 0.47), and high-risk pregnancy (0.44). Performance of ESS was poor with pooled sensitivity and specificity of 0.44 (95%CI: 0.33, 0.56; I² = 32.8%) and 0.62 (95%CI: 0.48, 0.75; I² = 81.55%), respectively. In conclusion, BQ and ESS showed poor performance during pregnancy, hence a new OSA screening questionnaire is needed. Registration: PROSPERO registration CRD42015025848.

Persistent and new-onset daytime sleepiness in pregnant women: A prospective observational cohort study

BACKGROUND

Daytime sleepiness is a frequent complaint in women during pregnancy. It has also been linked to negative obstetric consequences. Although high prevalence of excessive daytime sleepiness throughout pregnancy is well-documented, neither the causes of persistent daytime sleepiness nor new-onset daytime sleepiness during pregnancy have been investigated. Identifying predictive factors may play an important role in the management of daytime sleepiness in pregnant women and improve prenatal care and maternal-fetal outcomes.

OBJECTIVES

To examine first-trimester maternal characteristics associated with the persistence and new-onset daytime sleepiness in pregnant women.

DESIGN

A longitudinal, prospective cohort design.

SETTING

One medical center in Taipei, Taiwan and participating women's homes.

PARTICIPANTS

A total of 204 pregnant women.

METHODS

First-trimester pregnant women recruited from an outpatient obstetric clinic at a medical center provided socio-demographic and health information, wore an actigraphy monitor for 7 days, and completed sleep, mood, and daytime sleepiness questionnaires. Data were collected again when the women were in the second and third trimester.

RESULTS

Thirty-one (15.2%) women experienced excessive daytime sleepiness that persisted across all three trimesters. Nulliparous women and women who snored in the first trimester were 2.28 and 2.10 times more at risk of being classified of persistent daytime sleepiness than multiparous women and women who did not snore in the first trimester, respectively. Thirty-one (15.2%) women developed new-onset daytime sleepiness with advancing gestation. Women were more likely to develop new-onset daytime sleepiness if they worked longer hours per week (OR=1.04, p<0.001), if they reported snoring (OR=6.75, p<0.001), and if they had elevated depressive symptoms in the first trimester of pregnancy (OR=1.09, p=0.01).

CONCLUSIONS

Snoring in the first trimester is involved in both the persistence and new-onset of daytime sleepiness with elevated depressive symptoms related to new-onset daytime sleepiness in pregnant women. Findings suggest that intervention strategies for alleviating daytime sleepiness in pregnant women should focus on managing snoring and symptoms of depression in early trimesters with special attention to nulliparous and employed women.

Sleep Disturbances and Symptoms of Depression and Daytime Sleepiness in Pregnant Women

BACKGROUND

Sleep disturbance, depression, and daytime sleepiness are among the most prevalent symptoms reported by women during pregnancy. However, available data on the association between sleep disturbances and symptoms of depression and daytime sleepiness in pregnant women are sparse and methodological limitations have been acknowledged. The purpose of the study was to examine objective and self-reported sleep disturbances and symptoms of depression and daytime sleepiness in a group of healthy pregnant women.

METHODS

A total of 274 third-trimester pregnant women wore a wrist actigraph continuously for 7 days to assess objective sleep quality and quantity. Self-reported sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI), with self-reported poor sleep quality defined as a PSQI score more than 5. The Center for Epidemiologic Studies-Depression Scale (CES-D) and Epworth Sleepiness Scale were used to evaluate symptoms of depression and daytime sleepiness, respectively.

RESULTS

Sixty-four (23.4%) women were at risk for clinical depression and 69 (25.2%) had daytime sleepiness. Risk of clinically meaningful depressive symptomatology was significantly increased in women with objective total nighttime sleep less than 6 hours (OR 2.53 [95% CI 1.26-5.08]) and self-reported poor sleep quality (OR 3.31 [95% CI 1.74-6.30]), even after multiple adjustment. Neither objective nor self-reported sleep disturbances increased daytime sleepiness in this group of pregnant women.

DISCUSSION

Both objective nighttime sleep less than 6 hours and self-reported poor sleep quality in healthy third-trimester pregnant women is associated with significant risks for clinical depression. Improving sleep would likely be associated with a reduction in depression symptom severity and an attenuation of the prevalence of depression in pregnant women.

Restless Legs Symptoms and Pregnancy and Neonatal Outcomes

PURPOSE

Restless legs syndrome (RLS) is a commonly occurring neurologic disorder that affects up to one third of women during pregnancy. RLS has been associated with increased sympathetic tone in the nonpregnant population. We examined whether a RLS surrogate is associated with a higher prevalence of pregnancy and neonatal outcomes.

METHODS

Data were analyzed from a cross-sectional survey of 1000 women interviewed soon after delivery by using an RLS surrogate question. Women were asked how frequently (0 = none, 1 = rarely [<1 time/week], 2 = sometimes [1-2 times/week], 3 = frequently [3-4 times/week], and 4 = always [5-7 times/week]) they had "experienced jumpy or jerky leg movements" in the last 3 months of pregnancy. Clinical charts were reviewed to obtain relevant demographic and clinical data, including the presence of gestational hypertensive disorders and neonatal outcomes at birth. Subjects who "always" experienced RLS were compared with subjects experiencing symptoms less frequently or not at all with respect to prevalence of gestational hypertensive disorder.

FINDINGS

The mean ([SD]) age, prepregnancy body mass index (BMI), and BMI at delivery were 29.0 (6.1) years, 26.1 (6.2) kg/m(2), and 32.0 (6.3) kg/m(2), respectively. The overall prevalence of the RLS surrogate (jumpy or jerky leg movements) was 35.5% with the following distribution on a Likert scale: score 1 = 6.4%; score 2 = 10.2%; score 3 = 8.1%; and score 4 = 10.8%. Chronic hypertension was present in 2.1%, pregnancy-induced hypertension in 9.5%, and preeclampsia in 4.5% of respondents. Subjects who reported "always" having sensations of jumpy or jerky legs were more likely to have gestational hypertensive disorders compared with those who reported less frequent occurrence of the symptoms. Adjusted odds ratios were 3.74 (95% CI, 1.31-10.72; P = 0.014) for chronic hypertension; 1.26 (95% CI, 0.65-2.46; P = 0.487) for pregnancy-induced hypertension; and 2.15 (95% CI, 0.97-4.75; P = 0.060) for preeclampsia. There was a significant association between leg movement score and neonatal birth weight (coefficient, -149.5 g [95% CI, -276.9 to -22.5]; P = 0.005) and gestational age at birth (-0.7 week [95% CI, -1.1 to -0.2]; P = 0.021) that persisted after adjusting for preeclampsia, diabetes, and smoking.

IMPLICATIONS

A higher frequency of jumpy or jerky leg symptoms, a proxy for RLS during pregnancy, was associated with a higher likelihood of gestational hypertensive disorders and neonatal outcomes such as gestational age at birth and birth weight. These findings may affect RLS treatment decisions during pregnancy.

Pulmonary Disorders in Pregnancy

Pregnancy is associated with some profound changes in the cardiovascular, respiratory, immune, and hematologic systems that impact the clinical presentation of respiratory disorders, their implications in pregnancy, and the decisions to treat. In addition, concerns for fetal well-being and safety of various interventions complicate the management of these disorders. In many circumstances, especially life-threatening ones, decisions are based upon a careful assessment of the risk benefit ratio rather than absolute safety of drugs and interventions. In this chapter, we review some of the common respiratory disorders that internists or obstetricians may be called upon to manage.

Placenta-secreted circulating markers in pregnant women with obstructive sleep apnea

AIMS

Obstructive sleep apnea (OSA) is associated with placenta-mediated adverse clinical outcomes. We aimed at comparing placenta-secreted proteins, such as first and second trimester Down syndrome screening markers which have been linked to preeclampsia, and markers of angiogenesis in pregnant women with OSA, and pregnant controls at low risk for OSA.

METHODS

A case-control study of pregnant women with OSA and controls at low risk for OSA was performed. Levels of first and second trimester markers were reported as multiple of median (MoM), and adjusted for body mass index (BMI). Stored samples were tested for markers of angiogenesis and adjusted for gestational age, BMI, and chronic hypertension.

RESULTS

A total of 24 women with OSA and 166 controls had screening markers. BMI was higher in cases compared to controls, P=0.01. MoM levels of placenta associated plasma protein-A (PAPP-A) were significantly lower in cases versus controls, even after adjusting for BMI (0.52 IQR 0.48 vs. 1.01 IQR 0.63, P=0.009). The ratio of soluble vascular endothelial growth factor receptor 1 to placental growth factor was significantly higher in cases than controls, even after adjusting for confounders (4.42 IQR 2.52 vs. 2.93 IQR 2.01, P=0.009).

CONCLUSION

Circulating placenta-secreted glycoproteins and markers of angiogenesis are altered in pregnant women with OSA.

Sleep disorders in pregnancy

Sleep disturbances are common in pregnancy and may be influenced by a multitude of factors. Pregnancy physiology may predispose to sleep disruption but may also result in worsening of some underlying sleep disorders, and the de novo development of others. Apart from sleep disordered breathing, the impact of sleep disorders on pregnancy, fetal, and neonatal outcomes is poorly understood. In this article, we review the literature and discuss available data pertaining to the most common sleep disorders in perinatal women. These include restless legs syndrome, insomnia, circadian pattern disturbances, narcolepsy, and sleep-disordered breathing.

Snoring during pregnancy and its relation to sleepiness and pregnancy outcome - a prospective study

BACKGROUND

The incidence of snoring and sleepiness is known to increase during pregnancy, and this might impact maternal health and obstetric outcome. However, the association between snoring and sleepiness during pregnancy is not fully understood. This study was aimed at investigating the development of snoring during pregnancy and prospectively assessing if there is an association between snoring and sleepiness or adverse pregnancy outcomes, such as preeclampsia, mode of delivery, and fetal complications.

METHODS

Consecutively recruited pregnant women (n = 500) received a questionnaire concerning snoring and sleep at the 1st and 3rd trimester of pregnancy. The women who had rated their frequency of snoring at both occasions (n = 340) were divided into subgroups according to the development of snoring they reported and included in the subsequent analyses. Additional medical data were collected from the medical records.

RESULTS

The frequency of snoring was 7.9% in the 1st trimester and increased to 21.2% in the 3rd trimester of pregnancy. The women who snored already in early pregnancy had significantly higher baseline BMI (p = 0.001) than the women who never snored, but snoring was not associated with the magnitude of weight gain during pregnancy. Snoring women were more likely to experience edema in late pregnancy than the non-snorers. Women who started to snore during pregnancy had higher Epworth Sleepiness Scores than the non snorers in both early and late pregnancy. No significant association between obstetric outcome and snoring was found.

CONCLUSION

Snoring does increase during pregnancy, and this increase is associated with sleepiness, higher BMI at the start of pregnancy and higher prevalence of edema, but not with weight gain.

Do pregnant women accurately report sleep time? A comparison between self-reported and objective measures of sleep duration in pregnancy among a sample of urban mothers

PURPOSE

Survey questions are commonly used to assess sleep duration because of their low cost and convenience. Responses to these questions correlate moderately with objectively measured sleep duration in nonpregnant individuals, but little is known about the validity of self-reported sleep measures in pregnancy. The aim of the present study was to determine the extent to which self-reported gestational sleep duration assessed by questionnaire predicted objectively measured gestational sleep duration via actigraphy.

METHODS

We analyzed data from 80 mothers enrolled in an ancillary study of Project BABIES, a prospective cohort study of urban, pregnant women. Sleep measurements were collected in midpregnancy and included 7 days of wrist actigraphy, a sleep log, and survey questions about sleep time adapted from the Pittsburgh Sleep Quality Index.

RESULTS

Mean measured gestational sleep duration derived from actigraphy was 6.87 h [standard deviation (SD) 0.87], and questionnaire-assessed nocturnal sleep time averaged 7.29 h (SD 1.84). While the difference between measures did not reach statistical significance (p = 0.07 for paired samples t test), over half (62 %) of participants reported a habitual average nightly sleep time that differed more than 1 h from their average actigraphically measured sleep duration (39 % overestimated by more than an hour; 23 % underestimated by more than an hour). There was no correlation between measures (r = 0.007; 95 % confidence interval -0.21, 0.23).

CONCLUSION

Questionnaire-derived reports of usual sleep hours do not reflect objectively measured sleep time in urban, pregnant women. Actigraphy is preferable to accurately assess gestational sleep duration.

Epworth sleepiness scale scores and adverse pregnancy outcomes

PURPOSE

Snoring is associated with adverse pregnancy outcomes including gestational hypertensive disorders, gestational diabetes, and Cesarean deliveries. The purpose of this study was to assess whether excessive daytime sleepiness (EDS) assessed by Epworth Sleepiness Scale (ESS) increases the risk of these complications further.

METHODS

Following institutional review board approval and informed consent, English-speaking women in the immediate postpartum period were systematically selected and recruited. Women answered a survey that included questions regarding symptoms of sleep-disordered breathing (SDB) using the multivariable apnea prediction index and excessive daytime sleepiness using ESS. Pregnancy and fetal outcomes were collected by review of medical records. Standard statistical analysis with multivariable logistic regression was performed. ESS was evaluated both as a continuous variable and with various cutoffs given that pregnant women are likely more sleepy at baseline than the general population.

RESULTS

In patients who underwent planned Cesarean delivery, mean ESS was significantly higher than in those with uncomplicated vaginal delivery, even after adjusting for confounders (adjusted odds ratio (aOR), 1.08; 95 % CI, 1.01-1.15; p = 0.02). There was no significant association between EDS (defined as ESS of >10) and gestational diabetes or gestational hypertensive disorders in snorers or non snorers. However, a significant association with gestational diabetes was found in patients with an ESS of >16 compared to those with an ESS of ≤16, even after multiple adjustments (aOR, 6.82; 95 % CI, 1.19-39.27), but the number of subjects in an ESS of >16 category was small.

CONCLUSIONS

There is an increased association between women with higher ESS and planned Cesarean delivery. Severe EDS was associated with gestational diabetes in pregnant women in a small sample size. Future studies in larger samples need to confirm the association of severe EDS and gestational diabetes and elucidate potential mechanisms of the links with adverse outcomes.