A review of sleep-promoting medications used in pregnancy

Sleep duration, napping behaviors and restless legs syndrome during pregnancy and the trajectories of ultrasonographic measures of fetal growth: Findings from the NICHD Fetal Growth Studies-Singletons

OBJECTIVES

Given the plausible mechanisms and the lacking of empirical evidence, the study aims to investigate how gestational sleep behaviors and the development of sleep disorders, such as restless legs syndrome, influence ultrasonographic measures of fetal growth.

METHODS

The study included 2457 pregnant women from the NICHD Fetal Growth Studies - Singletons (2009-2013), who were recruited between 8-13 gestational weeks and followed up to five times during pregnancy. Women were categorized into six groups based on their total sleep hours and napping frequency. The trajectory of estimated fetal weight from 10-40weeks was derived from three ultrasonographic measures. Linear mixed effect models were applied to model the estimated fetal weight in relation to self-reported sleep-napping behaviors and restless legs syndrome status, adjusting for age, race and ethnicity, education, parity, prepregnancy body mass index category, infant sex, and prepregnancy sleep-napping behavior.

RESULTS

From enrollment to near delivery, pregnant women's total sleep duration and nap frequency declined and restless legs syndrome symptoms frequency increased generally. No significant differences in estimated fetal weight were observed by sleep-napping group or by restless legs syndrome status. Results remained similar in sensitivity analyses and stratified analyses by women's prepregnancy body mass index category (normal vs. overweight/obese) or by infant sex.

CONCLUSIONS

Our data indicate that there is no association between sleep during pregnancy-assessed as total sleep duration and napping frequency, nor restless legs syndrome symptoms-and fetal growth from weeks 10 to 40 in healthy pregnant women.

Prescription Patterns and Predisposing Factors of Benzodiazepine and Z-Hypnotic Use During Pregnancy: A Nationwide Cohort Study

PURPOSE

The use of benzodiazepines and Z-hypnotics during pregnancy has raised significant concerns in recent years. However, there are limited data that capture the prescription patterns and predisposing factors in use of these drugs, particularly among women who have been long-term users of benzodiazepines and Z-hypnotics before pregnancy.

METHODS

This population-based cohort study comprised 2 930 988 pregnancies between 2004 and 2018 in Taiwan. Women who were dispensed benzodiazepines or Z-hypnotics during pregnancy were identified and further stratified into groups based on their status before pregnancy: long-term users (with a supply of more than 180 days within a year), short-term users (with a supply of less than 180 days within a year), and nonusers. Trends in the use of benzodiazepines or Z-hypnotics and concomitant use with antidepressants or opioids were assessed. Logistic regression models were utilized to identify factors associated with use of these drugs during pregnancy, and interrupted time series analyses (ITSA) were employed to evaluate utilization patterns of these drugs across different pregnancy-related periods.

RESULTS

The overall prevalence of benzodiazepine and Z-hypnotic use was 3.5% during pregnancy. Among prepregnancy long-term users, an upward trend was observed. The concomitant use of antidepressants or opioids among exposed women increased threefold (from 8.6% to 23.1%) and sixfold (from 0.3% to 1.7%) from 2004 to 2018, respectively. Women with unhealthy lifestyle behaviors, such as alcohol abuse (OR 2.48; 95% CI, 2.02-3.03), drug abuse (OR 10.34; 95% CI, 8.46-12.64), and tobacco use (OR 2.19; 95% CI, 1.96-2.45), as well as those with psychiatric disorders like anxiety (OR 6.99; 95% CI, 6.77-7.22), insomnia (OR 15.99; 95% CI, 15.55-16.45), depression (OR 9.43; 95% CI, 9.07-9.80), and schizophrenia (OR 21.08; 95% CI, 18.76-23.69), and higher healthcare utilization, were more likely to use benzodiazepines or Z-hypnotics during pregnancy. ITSA revealed a sudden decrease in use of benzodiazepines and Z-hypnotics after recognition of pregnancy (level change -0.55 percentage point; 95% CI, -0.59 to -0.51). In contrast, exposures to benzodiazepines and Z-hypnotics increased significantly after delivery (level change 0.12 percentage point; 95% CI, 0.09 to 0.16).

CONCLUSIONS

In this cohort study, an increased trend of benzodiazepine and Z-hypnotic use during pregnancy among prepregnancy long-term users, as well as concomitant use with antidepressants or opioids were found. The findings have highlighted the existence of various risk factors associated with the use of these drugs during pregnancy. Utilization patterns varied across different stages of pregnancy, highlighting the need for prescription guidelines and educational services for women using these drugs during pregnancy.

Prevalence of benzodiazepines use during pregnancy in Lebanon

Pregnancy is a period of heightened risk period for many psychiatric disorders, particularly anxiety disorders. However, there is limited knowledge regarding the usage of psychotropic medications during pregnancy. Over the past decade there has been a notable increase in the use of medications during pregnancy, with benzodiazepines being the primary choice for alleviating anxiety. It is important to note, though, that benzodiazepines have been associated with various risks for both pregnancy and newborns. In Lebanon, to date, there has been no study estimating the prevalence of the use of benzodiazepines during pregnancy. Our study aims to find the prevalence of benzodiazepines use in a population of pregnant women in Hôtel-Dieu Hospital, a tertiary care center in Beirut, and the medical center of Saint-Joseph University and to compare our results to international literature. To accomplish our objectives we administered questionnaires to over two hundred women who had recently given birth in the gynecology department. These forms encompassed inquiries about benzodiazepine consumption, as well as various medical and socio demographic details. In total, we interviewed 225 women who gave birth at the Hôtel-Dieu de France between the months of December 2019 and February 2020 and between the months of February 2021 and October 2021 in the gynecology department. The questionnaires included socio demographic, medical, and psychiatric information as well as questions about the use of benzodiazepines. We found a significantly lower prevalence of benzodiazepine use among these women compared to the figures reported in international literature. The approval of the ethics committee was obtained on December 19, 2019 after making sure that this study raised no ethical objections. (File number: CEHDF 1533).

Maternal exposure to zolpidem and risk of specific birth defects

Zolpidem is a non-benzodiazepine agent indicated for treatment of insomnia. While zolpidem crosses the placenta, little is known about its safety in pregnancy. We assessed associations between self-reported zolpidem use 1 month before pregnancy through to the end of the third month ("early pregnancy") and specific birth defects using data from two multi-site case-control studies: National Birth Defects Prevention Study and Slone Epidemiology Center Birth Defects Study. Analysis included 39,711 birth defect cases and 23,035 controls without a birth defect. For defects with ≥ 5 exposed cases, we used logistic regression with Firth's penalised likelihood to estimate adjusted odds ratios and 95% confidence intervals, considering age at delivery, race/ethnicity, education, body mass index, parity, early-pregnancy antipsychotic, anxiolytic, antidepressant use, early-pregnancy opioid use, early-pregnancy smoking, and study as potential covariates. For defects with three-four exposed cases, we estimated crude odds ratios and 95% confidence intervals. Additionally, we explored differences in odds ratios using propensity score-adjustment and conducted a probabilistic bias analysis of exposure misclassification. Overall, 84 (0.2%) cases and 46 (0.2%) controls reported early-pregnancy zolpidem use. Seven defects had sufficient sample size to calculate adjusted odds ratios, which ranged from 0.76 for cleft lip to 2.18 for gastroschisis. Four defects had odds ratios > 1.8. All confidence intervals included the null. Zolpidem use was rare. We could not calculate adjusted odds ratios for most defects and estimates are imprecise. Results do not support a large increase in risk, but smaller increases in risk for certain defects cannot be ruled out.

Sleep disturbance and its associated factors among pregnant women in Ethiopia: systematic review and meta-analysis

INTRODUCTION

Globally, sleep disturbance is the foremost public health issue among pregnant women which might have undesirable birth outcome including neurocognitive impairment, preterm birth, low birth weight, and neonatal morbidity and mortality. In Ethiopia, inconsistent findings have been reported on the prevalence of sleep disturbance among pregnant women. Therefore, this review aims to estimate the pooled prevalence sleep disturbance and its associated factors among pregnant women in Ethiopia.

METHODS

This systematic review and meta-analysis of observational studies was designed according to the PRISMA guideline. A systematic search of literature was conducted in PubMed, Scopus, Web of science, and Google Scholar using relevant searching key terms. The Newcastle-Ottawa scale was used to evaluate the quality of all selected articles. Data were analyzed using STATA Version 14 software. Publication bias was checked using Egger's test and funnel plot. Cochran's chi-squared test and I2 values were used to assess heterogeneity. A fixed-effects model was applied during meta-analysis.

RESULTS

In this review, six studies were included after reviewing 17,100 articles. The pooled prevalence of sleep disturbance among pregnant women in Ethiopia was 50.43% (95%CI: 39.34-61.52). Third trimester pregnancy AOR = 4.03; 95% CI: 2.84,5.71), multigravidity (AOR = 1.99; 95% CI: 1.54, 2.59), unplanned pregnancy (AOR = 2.56; 95% CI: 1.52,4.31), depression (AOR = 3.57; 95% CI: 2.04, 6.27), stress (AOR = 2.77; 95% CI: 1.57, 4.88), anxiety (AOR = 3.69; 95% CI: 1.42, 9.59) and poor sleep hygiene (AOR = 2.49; 95% CI: 1.56, 3.99) and were statistically associated with sleep disturbance among pregnant women.

CONCLUSION

This review revealed that the magnitude of sleep disturbance among pregnant woman in Ethiopia was relatively high and multiple factors determined the likelihood of having a disturbed sleep-awake pattern. Thus, the implementation of interventions for sleep disturbance after screening pregnant women is needed. Moreover, public health interventions targeted on the prevention of unintended pregnancy and depression during pregnancy should be implemented.

Over-The-Counter Drugs and Pregnancy

The obstetric provider should ask about over-the-counter drugs, although most are low dose, used only briefly, and any harm is unlikely and more theoretic than real.

Substance Exposure and Adverse Neonatal Outcomes: A Population-Based Cohort Study

OBJECTIVE

To estimate the independent and combined effects of in utero exposures on birth outcomes in a rural population.

STUDY DESIGN

The study used population-level data (2020-2022) from a state-wide surveillance tool (Working in Appalachia to identify at-risk infants, Critical congenital heart disease, and Hearing loss) in West Virginia. Outcomes included low birth weight, preterm birth, small for gestational age, and birth weight in grams. Exposure included a composite variable with 8 levels of 3 exposure (opioids, stimulants, and cannabis) categories. Analyses were adjusted for sociodemographic covariates using multiple logistic and linear regression analyses.

RESULTS

Of the 34 412 singleton live births, 1 in 8 newborns (12.2%) had in utero exposure(s) to opioids, stimulants, and/or cannabis, 11.5% were preterm, 7.9% had low birthweight, 9.6% were small for gestational age, and mean birth weight was 3249 ± 563.6 g. Preterm birth was associated with stimulant alone exposure (aOR, 1.40; 95% CI, 1.03-1.89) and stimulant and cannabis concurrent exposure (aOR, 1.69; 95% CI, 1.16, 2.47). Low birthweight was associated with opioids alone (aOR, 1.34; 95% CI, 1.10, 1.63), cannabis alone (aOR, 1.31; 95% CI, 1.13 to -1.52), opioid and cannabis (aOR, 1.61; 95% CI, 1.12 to -2.31), and opioids, stimulants, and cannabis concurrent exposures (aOR, 2.27; 95% CI, 1.43-3.61). Five exposure categories were associated with lower birth weights (adjusted mean difference range. -72 to -211 g). Small for gestational age was associated with opioids alone (aOR, 1.48; 95% CI, 1.24-1.78), cannabis alone (aOR, 1.49; 95% CI, 1.31-1.69), and opioids and cannabis concurrent exposures (aOR, 1.91; 95% CI, 1.36-2.67).

CONCLUSIONS

We showed complex associations between in utero substance exposures, preterm birth, birth weight, and sociodemographic factors in a rural population. The results may inform policy efforts to improve maternal and child health in socioeconomically disadvantaged and underserved rural populations.

Prevalence of exposure to benzodiazepines among pregnant women in Taiwan: A nationwide longitudinal study

Although more than one hundred studies have examined the prevalence of the use of benzodiazepines and benzodiazepine-like Z-hypnotics (BZDs) among pregnancy events, further analysis of the effects of dosage or type of BZDs is needed. The aim of this study was to examine the prevalence rate of BZDs use in pregnancy events, stratified by trimester over time, with characteristics of the dosage and type of BZDs. This is a retrospective population study based on linking three national databases. We examined the prevalence rates from 2004 to 2017, and contrasted the results based on >0 defined daily dose (DDD) and ≥0.5 DDD. We identified 2,630,944 pregnancy events with live births; 89,897 (3.4%) of the associated pregnancy events had used some form of BZD during pregnancy. The prevalence of BZDs use, as defined by >0 DDD, decreased from 4.1% in 2004 to 2.9% in 2017, indicating a decrease in sporadic use and an increase in stable use within therapeutic doses. Meanwhile, BZDs use defined by ≥0.5 DDD increased from 0.1% in 2004 to 0.4% in 2017. Zolpidem was the most frequently prescribed BZDs, as defined by >0 DDD or ≥0.5 DDD. This national cohort study demonstrates the importance of average dosage in the definition of BZDs use in pregnancy events, and it found opposite trends in the prevalence of use between different dosages.

Hypnotic benzodiazepine receptor agonist exposure during pregnancy and the risk of congenital malformations and other adverse pregnancy outcomes: A systematic review and meta-analysis

OBJECTIVE

To determine if there is an association between antenatal hypnotic benzodiazepine receptor agonist exposure and congenital malformations or other adverse pregnancy outcomes in the offspring.

METHODS

Databases were searched to January 31, 2021. Cohort studies published in English on congenital malformations or other adverse pregnancy outcomes in infants following exposure compared with those unexposed, were summarized and meta-analyzed where possible.

RESULTS

Following screening, 25 studies were assessed for eligibility and seven included in the meta-analyses. Five studies were pooled for congenital malformations following first trimester exposure and not statistically significant (OR 0.87, 95% CI 0.56-1.36). The five studies that assessed for preterm birth following anytime exposure did pool to a statistically significant effect (OR 1.49, 95% CI 1.19-1.86); study quality, control for other psychotropic drugs and psychiatric diagnosis did not appear to be moderators. There were two missing studies when examining for publication bias in both of the main analyses above but the revised estimates were similar to the original. Low birth weight (LBW) was significant (three studies, any time exposure, OR 1.51, 1.27-1.78) as was small for gestational age (SGA) (three studies with anytime exposure, OR 1.34, 1.22-1.48). There were too few studies to summarize birth weight, gestational age, respiratory difficulties, APGAR score at 5 min and NICU admission.

CONCLUSIONS

Pregnancy exposure to hypnotics was not associated with a higher risk for congenital malformations but was associated with an increased risk for preterm birth, LBW and SGA compared with those infants who were not exposed. These findings are consistent with the antidepressant and benzodiazepine literature.

Examining Experiences of Poor Sleep During Pregnancy: A Qualitative Study to Inform the Development of a Prenatal Sleep Intervention

Background

Poor sleep is common during pregnancy and is associated with increased risk of negative health outcomes. Research indicates that physical discomfort and having an active mind are primary factors for prenatal sleep disturbances. Mindfulness-based interventions have the potential for addressing these factors, but have yet to be optimized for this purpose in this population.

Objective

The objective of this study was to gather input from pregnant and postpartum individuals about the value of a mindfulness-based program for improving prenatal sleep and their preferred content and delivery format.

Methods

We conducted 2 focus groups with 12 pregnant people experiencing poor sleep quality and 3 individual interviews with postpartum people. Interviews were thematically analyzed.

Results

The majority of participants expressed strong interest in a mindfulness program for improving prenatal sleep. Participants reported that pregnancy-specific physical discomfort and worry (both general and pregnancy-specific) affected their sleep. Participants wanted sleep education, and strategies for calming the mind, reducing physical discomfort, reducing impact of bedtime partners on sleep, and tips for improving sleep schedule and quality. Participants recognized the convenience of an online intervention and the social benefits of an in-person intervention and favored a hybrid delivery model.

Conclusion

Addressing prenatal sleep problems is an unmet need. Given the challenges and discomfort women face during pregnancy, and the importance of adequate sleep for promoting mental and physical health during pregnancy, sleep difficulties are critical to address. A mindfulness-based intervention for improving prenatal sleep was deemed of high interest to this perinatal population.

Examining Patient Feedback and the Role of Cognitive Arousal in Treatment Non-response to Digital Cognitive-behavioral Therapy for Insomnia during Pregnancy

OBJECTIVE

Insomnia affects over half of pregnant and postpartum women. Early evidence indicates that cognitive-behavioral therapy for insomnia (CBTI) improves maternal sleep and mood. However, standard CBTI may be less efficacious in perinatal women than the broader insomnia population. This study sought to identify patient characteristics in a perinatal sample associated with poor response to CBTI, and characterize patient feedback to identify areas of insomnia therapy to tailor for the perinatal experience.

PARTICIPANTS

Secondary analysis of 46 pregnant women with insomnia symptoms who were treated with digital CBTI in a randomized controlled trial.

METHODS

We assessed insomnia, cognitive arousal, and depression before and after prenatal treatment, then 6 weeks postpartum. Patients provided feedback on digital CBTI.

RESULTS

Residual cognitive arousal after treatment was the most robust factor associated with treatment non-response. Critically, CBTI responders and non-responders differed on no other sociodemographic or pretreatment metrics. After childbirth, short sleep (<6 hrs/night) was associated with maternal reports of poor infant sleep quality. Patient feedback indicated that most patients preferred online treatment to in-person treatment. Although women described digital CBTI as convenient and helpful, many patients indicated that insomnia therapy would be improved if it addressed sleep challenges unique to pregnancy and postpartum. Patients requested education on maternal and infant sleep, flexibility in behavioral sleep strategies, and guidance to manage infant sleep.

CONCLUSIONS

Modifying insomnia therapy to better alleviate refractory cognitive arousal and address the changing needs of women as they progress through pregnancy and early parenting may increase efficacy for perinatal insomnia.Name: Insomnia and Rumination in Late Pregnancy and the Risk for Postpartum DepressionURL: clinicaltrials.govRegistration: NCT03596879.

The Association Between Sleep Disorders and Incidence of Dry Eye Disease in Ningbo: Data From an Integrated Health Care Network

PURPOSE

To investigate the association between sleep disorders and dry eye disease (DED) in Ningbo, China.

METHODS

Our data came from the Yinzhou Health Information System (HIS), including 257932 patients and was based on a 1:1 matching method (sleep disorder patients vs. patients without sleep disorders) during 2013-2020. Sleep disorders and DED were identified using ICD-10 codes. Cox proportional hazards regression was used to identify the association between sleep disorders and DED.

RESULTS

The eight-year incidence of DED was significantly higher in participants with diagnosis of sleep disorders (sleep disorders: 50.66%, no sleep disorders: 16.48%, P < 0.01). Sleep disorders were positively associated with the diagnosis of DED (HR: 3.06, 95% CI: 2.99-3.13, P < 0.01), when sex, age, hypertension, diabetes and other systemic diseases were adjusted. In the sleep disorders patients, advancing age, female sex, and presence of coexisting disease (hypertension, diabetes, hyperlipidemia, thyroid disease, depression, heart disease, and arthritis) were significantly associated with the development of DED by the multivariate cox regression analysis (all P < 0.05).In addition, there was a significantly positive association between estazolam and the incidence of DED in both sleep disorder and non-sleep disorder groups (all P < 0.05).

CONCLUSIONS

Sleep disrder was associated with a three-time increased risk of DED. This association can be helpful in effective management of both sleep disorders and DED.

A randomized controlled trial on the effects of blue-blocking glasses compared to partial blue-blockers on sleep outcomes in the third trimester of pregnancy

OBJECTIVE

Sleep disturbances are common in pregnancy. Blocking blue light has been shown to improve sleep and may be a suitable intervention for sleep problems during pregnancy. The present study investigated the effects of blue light blocking in the evening and during nocturnal awakenings among pregnant women on primary sleep outcomes in terms of total sleep time, sleep efficiency and mid-point of sleep.

METHODS

In a double-blind randomized controlled trial, 60 healthy nulliparous pregnant women in the beginning of the third trimester were included. They were randomized, using a random number generator, either to a blue-blocking glass intervention (n = 30) or to a control glass condition constituting partial blue-blocking effect (n = 30). Baseline data were recorded for one week and outcomes were recorded in the last of two intervention/control weeks. Sleep was measured by actigraphy, sleep diaries, the Bergen Insomnia Scale, the Karolinska Sleepiness Scale and the Pre-Sleep Arousal Scale.

RESULTS

The results on the primary outcomes showed no significant mean difference between the groups at posttreatment, neither when assessed with sleep diary; total sleep time (difference = .78[min], 95%CI = -19.7, 21.3), midpoint of sleep (difference = -8.9[min], 95%CI = -23.7, 5.9), sleep efficiency (difference = -.06[%], 95%CI = -1.9, 1.8) and daytime functioning (difference = -.05[score points], 95%CI = -.33, .22), nor by actigraphy; total sleep time (difference = 13.0[min], 95%CI = -9.5, 35.5), midpoint of sleep (difference = 2.1[min], 95%CI = -11.6, 15.8) and sleep efficiency (difference = 1.7[%], 95%CI = -.4, 3.7). On the secondary outcomes, the Bergen Insomnia Scale, the Karolinska Sleepiness Scale and the Pre-Sleep Arousal Scale the blue-blocking glasses no statistically significant difference between the groups were found. Transient side-effects were reported in both groups (n = 3).

CONCLUSIONS

The use of blue-blocking glasses compared to partially blue-blocking glasses in a group of healthy pregnant participants did not show statistically significant effects on sleep outcomes. Research on the effects of blue-blocking glasses for pregnant women with sleep-problems or circadian disturbances is warranted.

TRIAL REGISTRATION

The trial is registered at ClinicalTrials.gov (NCT03114072).

Transcranial Electrical Stimulation for Relief of Peripartum Mental Health Disorders in Women Undergoing Cesarean Section With Combined Spinal-Epidural Anesthesia: A Pilot Randomized Clinical Trial

OBJECTIVE

This study aimed to explore transcranial electrical stimulation (tES) to relieve peripartum anxiety and depressive symptoms in women undergoing cesarean section with combined spinal-epidural anesthesia.

METHODS

This double-blind, randomized, sham-controlled trial was conducted in the Affiliated Hospital of Xuzhou Medical University from March 2021 and May 2021. One hundred and forty-eight full-term parturients giving birth by elective cesarean section were selected, and 126 were included in the intent-to-treat analysis. Parturients were provided standardized anesthesia and randomized to the active-tES (a-tES) group and sham-tES group. Parturients and outcome assessors were blinded to treatment allocation. The primary outcome was the changes in peripartum mental health disorders, including anxiety, assessed by the Pregnancy-Related Anxiety Questionnaire-Revised 2 (PRAQ-R2). Secondary outcomes included peripartum depressive symptoms, assessed by the Edinburgh Postnatal Depression Scale (EPDS), maternal satisfaction, fatigue level, sleep quality index, and pain score during and after operation. Data were collected before entering the operating room (T0), between post-anesthesia and pre-surgery (T1), before leaving the operating room (T2), and at 24 h post-surgery (T3).

RESULTS

One hundred and twenty-six eligible parturients were enrolled in the two groups: a-tES group (N = 62) and sham-tES group (N = 64). Treatment with tES resulted in significantly lower scores of anxiety compared with sham-tES (T2: P < 0.001; T3: P = 0.001). Moreover, the a-tES groups showed a significant reduction in depression scores (T2: P = 0.003; T3: P = 0.032).

CONCLUSION

In this randomized pilot study, tES treatment is efficacious in alleviating peripartum anxiety and depressive symptoms in women undergoing cesarean section and has been demonstrated to be a novel strategy for improving peripartum mental health disorders.

CLINICAL TRIAL REGISTRATION

[www.chictr.org.cn], identifier [ChiCTR2000040963].

Mind-Body Techniques in Pregnancy and Postpartum

Maternal stress can perturb physiology and psychiatric health leading to adverse outcomes. This review investigates the effectiveness of several mind-body therapies-namely biofeedback, progressive muscle relaxation, guided imagery, tai chi, and yoga-as interventions in reducing maternal stress and other pregnancy-related conditions. Through randomized trials, these techniques have shown promising benefits for reducing pain, high blood pressure, stress, anxiety, depressive symptoms, labor pain and outcomes, and postpartum mood disturbances. As these interventions are easy to implement, low cost, and safe to perform in pregnancy, they should be considered as alternative, nonpharmaceutical interventions to use during pregnancy and postpartum care.

Benzodiazepine exposures among women of reproductive age in the US, 2004-2018

Benzodiazepines, often used to treat anxiety, insomnia, and other conditions, are prescribed more frequently to women than men, and emergency department visits and overdose deaths involving benzodiazepines have increased significantly among women in recent years. This study describes characteristics and trends associated with benzodiazepine exposures among women of reproductive age (15-49 years old) that were reported to United States poison control centers from 2004 through 2018. The National Poison Data System recorded 258,370 first-ranked benzodiazepine exposures among women 15-49 years old during the study period. More than one-half (56.9%) of exposures involved a single-substance and one-third (34.0%) occurred among women 20-29 years old. The majority were categorized as "intentional, suspected suicide" (73.2%) or "intentional" (12.9%). Exposures frequently resulted in admission to a psychiatric facility (20.6%), critical care unit (18.1%), or non-critical care unit (9.3%). Twenty percent of cases resulted in a serious medical outcome, including 205 deaths. The substantial percentage of benzodiazepine exposures among women of reproductive age that were intentional and associated with suicide attempts or suicide deaths indicate that increased prevention efforts are needed to address this issue.

A New Safety Scoring System for the Use of Psychotropic Drugs During Lactation

BACKGROUND

Psychotropic drugs are frequently used to treat postpartum women with psychiatric diagnoses, especially psychotic disorder, major depression, and bipolar mood episodes. Pharmacotherapy in breastfeeding mothers is a major challenge.

STUDY QUESTION

This article presents a new safety scoring system for the use of psychotropic drugs during lactation.

STUDY DESIGN

The scoring system is based on the following 6 safety parameters: reported total sample, reported maximum relative infant dose, reported sample size for relative infant dose, infant plasma drug levels, prevalence of reported any adverse effect, and reported serious adverse effects. The total score ranges from 0 to 10. Higher scores represent a higher safety profile.

RESULTS

According to this scoring system, sertraline and paroxetine, respectively, had the highest scores representing "very good safety profile." Citalopram, olanzapine, and midazolam were assigned to "good safety profile." Among drugs evaluated in this article, trifluoperazine, aripiprazole, amisulpride, clozapine, doxepin, zaleplon, and zolpidem are not recommended owing to safety scores ≤3.

CONCLUSIONS

Most psychotropic drugs examined in this article have "moderate" or "low" safety profile.

Pharmacological Management of Insomnia

Insomnia is a highly prevalent condition associated with significant morbidity, reduction in quality of life, and increase in healthcare costs, and is a risk factor for multiple physical and mental disorders. The primary treatment modality is cognitive behavioral therapy for insomnia (CBT-I) but this is associated with difficulties with access and higher cost as well as poor response in some patients. Therefore, pharmacotherapy for insomnia is common and hypnotic agents are among the most frequently prescribed medications in the United States. Older medications for insomnia are limited by their side effect burden and narrow therapeutic window. Newer hypnotics, on the other hand, have been shown to have a better safety profile and longer term efficacy. While some studies have shown that long-term hypnotic use is associated with adverse outcomes, the current evidence is equivocal. The decision to treat chronic insomnia disorder with long-term hypnotics should be individualized and balance the potential risks of continuing hypnotic medication use with the risks of untreated persistent insomnia and associated functional limitations. This clinical review discusses the currently available medication options to treat insomnia, their mechanisms of action, dosing, and side effect profiles. This review also provides guidance on long-term management of hypnotics and the use of these medications in the elderly, those with medical comorbidities, and other special populations.

A Review of Sleep Architecture and Sleep Changes During Pregnancy

Importance

Poor sleep is widely recognized as a common complaint in pregnancy, and yet there are incomplete data on the exact nature of these complaints, what their implications for fetal and maternal health are, and how to best recognize and address these significant health issues.

Objectives

The purpose of this article is to review the current literature on the changes in objectively measured sleep parameters that occur during pregnancy, identify any possible trends, and discuss current implications for obstetric outcomes and treatments.

Evidence Acquisition

PubMed NCBI and Google Scholars database were searched for a variety of sleep-related terms, and articles were selected based on relevance to the topic and method of sleep pattern monitoring.

Results

Poor sleep is ubiquitous during pregnancy, and the relatively few studies evaluating the issue using objective polysomnography have small sample sizes. However, data suggests sleep architecture changes begin as early as the first trimester, and there is evidence that primigravid sleep structure never returns to prepregnancy levels after birth. In addition, cesarean delivery frequency, early labor, labor length, depression, gestational hypertension, and gestational diabetes all appear to be influenced by sleep changes. Current treatments are based on nonpregnant populations and may not be appropriate for the gravid patient.

Conclusions and Relevance

Disordered sleep is a more widespread and serious issue than most women are aware, and there are numerous obstetric and general health implications to cause clinician concern. More research is needed on both electroencephalography architecture changes and treatment options.

Insomnia symptoms during pregnancy: A meta-analysis

Reports of sleep disturbances are common during pregnancy, yet estimates of prevalence of insomnia symptoms during pregnancy vary widely. The goals of the current review were to summarize the existing data on prevalence of insomnia symptoms during pregnancy and to explore potential moderators, including trimester, gestational age, maternal age, symptoms of anxiety and symptoms of depression. A systematic search of PubMed, PsycInfo and Web of Science was conducted for articles published from inception up to June 2020. In total, 24 studies with a total of 15,564 participants were included in the analysis. The overall prevalence of insomnia symptoms during pregnancy was 38.2%. Trimester was a significant moderator, such that prevalence of insomnia symptoms was higher in the third trimester (39.7%) compared to first (25.3%) and second (27.2%) trimesters. No other variables significantly moderated the prevalence of insomnia symptoms. The results of the current meta-analysis suggest that the prevalence of insomnia symptoms is higher during pregnancy, particularly in the third trimester. Future research should examine the efficacy and safety of insomnia treatments with this population.

Prevalence of benzodiazepines and benzodiazepine-related drugs exposure before, during and after pregnancy: A systematic review and meta-analysis

BACKGROUND

Maternal use of benzodiazepines during pregnancy is common and has increased over the last decades. In this systematic review and meta-analysis, we studied the literature to estimate the worldwide use of benzodiazepines before, during and after pregnancy, which could help to estimate benzodiazepine exposure and to prioritize and guide future investigations.

METHODS

We systematically searched Embase, Medline Ovid, Web of Science and Cochrane Central up until July 2019 for studies reporting on benzodiazepine use before (12 months), during and after pregnancy (12 months). Random effects meta-analysis was conducted to calculate pooled prevalence estimates, as well as stratified according to substantive variables.

RESULTS

We identified 32 studies reporting on 28 countries, together reporting on 7,343,571 pregnancies. The worldwide prevalence of benzodiazepine use/prescriptions during pregnancy was 1.9% (95%CI 1.6%-2.2%; I² 97.48%). Highest prevalence was found in the third trimester (3.1%; 95%CI 1.8%-4.5%; I² 99.83%). Lorazepam was the most frequently used/prescribed benzodiazepine (1.5%; 95%CI 0.5%-2.5%; I² 99.87%). Highest prevalence was found in Eastern Europe (14.0%; 95%CI 12.1%-15.9%; I² 0.00%).

LIMITATIONS

All analyses revealed considerable heterogeneity.

CONCLUSIONS

Our meta-analysis confirmed that benzodiazepine use before, during and after pregnancy is prevalent. The relatively common use of benzodiazepines with possible risks for both mother and (unborn) child is worrying and calls for prescription guidelines for women, starting in the preconception period. Given the substantial proportion of children exposed to benzodiazepines in utero, future research should continue to study the short- and long-term safety of maternal benzodiazepine use during pregnancy and to explore non-pharmacological alternative treatments.

A randomized controlled trial of digital cognitive behavioral therapy for insomnia in pregnant women

OBJECTIVE

Despite high rates of prenatal insomnia, efficacious treatment options for this population are quite limited. Early evidence from randomized controlled trials (RCTs) support the efficacy of face-to-face cognitive-behavioral therapy for insomnia (CBTI) for prenatal insomnia. Yet, as many patients are unable to access this specialist-driven care, a critical need exists to increase its accessibility. This RCT examined the efficacy internet-based digital CBTI in pregnant women with insomnia.

METHODS

Single-site RCT. A total of 91 pregnant women (29.03 ± 4.16 years) nearing/entering the third trimester who screened positive for clinical insomnia on the Insomnia Severity Index (ISI) were randomized to digital CBTI or digital sleep education control. The ISI, Pittsburgh Sleep Quality Index (PSQI), Edinburgh Postnatal Depression Scale (EPDS), and Pre-Sleep Arousal Scale's Cognitive factor (PSAS-C) served as study outcomes, which were collected before treatment and after treatment during pregnancy, then six weeks after childbirth.

RESULTS

From pre to posttreatment, CBTI patients reported reductions in ISI (-4.91 points, p < 0.001) and PSQI (-2.98 points, p < 0.001) and increases in nightly sleep duration by 32 min (p = 0.008). Sleep symptoms did not change during pregnancy in the control group. After childbirth, CBTI patients, relative to controls, slept longer by 40 min per night (p = 0.01) and reported better sleep maintenance. No pre or postnatal treatment effects on depression or cognitive arousal were observed.

CONCLUSIONS

Digital CBTI improves sleep quality and sleep duration during pregnancy and after childbirth. To better optimize outcomes, CBTI should be tailored to meet the changing needs of women as the progress through pregnancy and early parenting. NAME: Insomnia and Rumination in Late Pregnancy and the Risk for Postpartum Depression. URL: clinicaltrials.gov. Registration: NCT03596879.

Racial/ethnic disparities in sleep duration and sleep disturbances among pregnant and non-pregnant women in the United States

Sleep disturbances among pregnant women are increasingly linked to suboptimal maternal/birth outcomes. Few studies in the USA investigating sleep by pregnancy status have included racially/ethnically diverse populations, despite worsening disparities in adverse birth outcomes. Using a nationally representative sample of 71,644 (2,349 pregnant) women from the National Health Interview Survey (2004-2017), we investigated relationships between self-reported pregnancy and six sleep characteristics stratified by race/ethnicity. We also examined associations between race/ethnicity and sleep stratified by pregnancy status. We used average marginal predictions from fitted logistic regression models to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for each sleep dimension, adjusting for sociodemographic and health characteristics. Pregnant women were less likely than non-pregnant women to report short sleep (PR_Overall  = 0.75; 95% CI, 0.68-0.82) and more likely to report long sleep (PR_Overall  = 2.06; 95% CI, 1.74-2.43) and trouble staying asleep (PR_Overall  = 1.34; 95% CI, 1.25-1.44). The association between pregnancy and sleep duration was less pronounced among women aged 35-49 years compared to those <35 years. Among white women, sleep medication use was less prevalent among pregnant compared to non-pregnant women (PR_White  = 0.45; 95% CI, 0.31-0.64), but this association was not observed among black women (PR_Black  = 0.98; 95% CI, 0.46-2.09) and was less pronounced among Hispanic/Latina women (PR_{Hispanic/Latina}  = 0.82; 95% CI, 0.38-1.77). Compared to pregnant white women, pregnant black women had a higher short sleep prevalence (PR_Black  = 1.35; 95% CI, 1.08-1.67). Given disparities in maternal/birth outcomes and sleep, expectant mothers (particularly racial/ethnic minorities) may need screening followed by treatment for sleep disturbances. Our findings should be interpreted in the historical and sociocultural context of the USA.

Effects of Exercise on Sleep Quality in Pregnant Women: A Systematic Review and Meta-analysis of Randomized Controlled Trials

PURPOSE

Sleep quality was considered a priority concern facing pregnant women. Conventional wisdom argues that good sleep quality benefits pregnant women and their fetuses. The aim of this study is to assess the effects of a specific exercise program on the　sleep quality in pregnant women.

METHODS

Searches were executed in seven databases since their inceptions until February 28, 2019, for randomized controlled trials evaluating the effects of an exercise program on the sleep quality and insomnia in pregnant women. A random-effects model was applied for meta-analysis, and odds ratio, mean differences (MDs), and 95% confidence intervals (CIs) are shown as parts of outcomes.

RESULTS

Seven studies were included for meta-analysis. Compared with their not-exercising counterparts, analyses showed that regularly exercising women had significantly enhanced sleep quality, with an odds ratio of 6.21 (95% CI, 2.02-19.11;p = .001; I² = 80.2%), with a standardized MD of -0.93 (95% CI, -1.19 to -0.67; p < .001; I² = 30.0%). However, exercising women showed no significant insomnia improvement, with an standardized MD of -2.85 (95% CI, -7.67 to 1.98; p = .250; I² = 97.0%), relative to their not-exercising counterparts.

CONCLUSION

This research indicated that exercise has a positive impact on the sleep quality of pregnant women. Despite the aforementioned positive impact on sleep quality, the present study did not find evidence to support that exercise may also improve insomnia for pregnant women.

Effect of Acupuncture on Pregnancy-Related Insomnia and Melatonin: A Single-Blinded, Randomized, Placebo-Controlled Trial

OBJECTIVE

The aim of the current study is to evaluate the efficacy and safety of acupuncture on sleep quality and overnight melatonin secretion, measured as urinary 6-sulfatoxymelatonin, in pregnant women.

PATIENTS AND METHODS

This randomized, parallel, single-blinded (participant), controlled trial was conducted on 72 pregnant women with insomnia. Study participants were randomly assigned to either the intervention, 10 sessions of acupuncture treatment over a 3-week period, or control group by block randomization (1:1). Patients in both groups were evaluated at baseline and post-treatment (third week) using the Pittsburgh Sleep Quality Index (PSQI) score (as the primary outcome) and urinary 6-sulfatoxymelatonin.

RESULTS

Fifty-five of 72 participants completed the study. There was no statistically significant difference regarding PSQI score and 6-sulfatoxymelatonin level between intervention and control groups at the baseline (P=0.169 and P=0.496). At the end of the study period, treatment with acupuncture significantly improved the PSQI score (P<0.001) with a large effect size of 3.7, as well as 6-sulfatoxymelatonin level (P=0.020) with a medium effect size of 0.6 as compared to the control group. No adverse effects were noted during acupuncture sessions and follow-up visits.

CONCLUSION

Acupuncture was shown to significantly improve the sleep quality in pregnant women, possibly through increasing melatonin secretion, and could be recommended as a low-cost and low-risk alternative treatment to pharmacological therapies.

Interventions for sleep problems during pregnancy: A systematic review

Sleep problems during pregnancy are prevalent and could be linked to negative outcomes during pregnancy or post-partum. However, these complaints are often underdiagnosed and undertreated. This review aimed to systematically assess the effectiveness of different interventions to ameliorate poor sleep quality and insomnia during pregnancy. Pubmed, PsycINFO and Medline databases were systematically searched without publication period restriction until 3rd May 2019. Eligible studies had to: include pregnant women of any age and gestational age; use clinical intervention designs targeted at improving sleep outcome; report pre- and post-treatment data for one or more sleep-related outcomes; be published in English, Italian, German, Spanish, or French. Sixteen studies were selected including 1252 expecting mothers. Studies evaluated the efficacy of various interventions: cognitive behavioral interventions for insomnia (4); pharmacotherapy (1); acupuncture (1); mindfulness and yoga (3); relaxation (5) and herbal medication (2). Only six were randomized controlled trials, and only four evaluated longitudinal outcomes. Preliminary support was found for all interventions, but our knowledge is still too limited by lack of evidence. There is an utmost urgency to perform high-quality randomized controlled trials for insomnia interventions during pregnancy and to implement effective programs in standard gynecological care.

Dry eye and sleep quality: a large community-based study in Hangzhou

Study Objectives

To investigate the relationship between dry eye and sleep quality in a large community-based Chinese population.

Methods

A total of 3,070 participants aged 18–80 were recruited from a community-based study in Hangzhou, China during 2016–2017. Sleep quality was evaluated using the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI), and dry eye was evaluated using the Ocular Surface Disease Index (OSDI) questionnaire. Multivariable linear regression and logistic regression models were used to investigate the associations, adjusting for age, smoking, drinking, season, and other potential confounders.

Results

Overall, CPSQI score and sleep dysfunction were significantly associated with mild, moderate, and severe dry eye (ORs for CPSQI score: 1.07, 1.13, 1.14, all p < 0.001; for sleep dysfunction: 1.31, 1.73, 1.66, all p < 0.05). Furthermore, worse OSDI score was presented in participants with worse CPSQI score or sleep dysfunction (CPSQI score > 7) (β: 0.13, 0.54; all p < 0.001). In addition, six of the seven components of CPSQI showed significant associations with dry eye (all p < 0.001), except for the component of sleep medication use. Moreover, we observed significant associations of dry eye in all three subscales of OSDI with CPSQI score and sleep dysfunction.

Conclusion

Our large, community-based study showed a strong association between poor sleep quality and an increased severity of dry eye, suggesting that preventing either one of the discomforts might alleviate the other.

A practical guide to the use of psychotropic medications during pregnancy and lactation

The use of psychotropic medications during the perinatal period is often met with fear and discomfort on the part of both clinicians and patients. There is a great deal of misinformation about the risks of medication use during pregnancy and lactation. The risk of untreated or undertreated mental illness during this time is an important consideration when making treatment recommendations. This paper serves as a practical guide for clinicians who may be treating patients with psychotropic medication during the perinatal period. A heuristic tool for making treatment decisions will be introduced, and coverage of specific psychiatric disorders and medication classes will be provided.

Sleep quality across pregnancy and postpartum: effects of parity and race

BACKGROUND

Despite high prevalence and clinical implications of disturbed sleep during pregnancy, information on changes in sleep across pregnancy and postpartum is incomplete. Moreover, predictors of differential patterns of sleep quality across the perinatal period are poorly defined.

METHODS

This study examined subjective sleep quality using the Pittsburgh Sleep Quality Index during each trimester of pregnancy and at 4-11 weeks postpartum among 133 women inclusive of nulliparous and multiparous African Americans and Whites.

RESULTS

At any given assessment, 53%-71% of women reported poor overall sleep quality (Pittsburgh Sleep Quality Index total score > 5). Moreover, 92% reported poor overall sleep quality during at least 1 assessment, including 88% at some time during gestation. Compared to nulliparous women, multiparous women reported poorer overall sleep quality, shorter sleep duration, and poorer sleep efficiency during the first trimester; poorer overall sleep quality and longer sleep latency in the second trimester; and more frequent sleep disturbances (eg, night time and early morning awakenings) during the third trimester. Among nulliparous as well as multiparous women, specific aspects of sleep (eg, subjective sleep quality, sleep disturbances, sleep efficiency) were poorer in African American compared to White women at different time points during pregnancy. No effects of race or parity were observed on sleep parameters at postpartum.

CONCLUSIONS

Poor sleep quality during pregnancy as well as early postpartum is highly prevalent among both African American and White women. Both multiparous status and African American race are associated with more disturbed sleep at some time points during pregnancy. These individual differences should be considered in future research and clinical efforts to promote perinatal sleep health.

Cognitive Behavioral Therapy for Insomnia and Women's Health: Sex as a Biological Variable

Differences in sleep for men and women begin at a very early age, with women reporting poorer sleep and having a higher risk for insomnia compared with men. Women are particularly vulnerable to developing insomnia during times of reproductive hormonal change. Sleep across the woman's lifespan and special treatment considerations for using cognitive behavioral therapy for insomnia (CBT-I) in women will be addressed in this review.

Identification and Treatment of Peripartum Anxiety Disorders

Anxiety disorders in the peripartum period are common and frequently overlooked. They can present de novo or as exacerbations of generalized anxiety disorder, obsessive compulsive disorder, panic disorder and social anxiety disorder, or posttraumatic stress disorder. Calculating a score on the Edinburgh postnatal depression scale is a useful method of screening for these disorders while also screening for perinatal depression. Treatment includes psychotherapy, specifically cognitive behavioral therapy, and antidepressants, the choice of which should be balanced between the severity of symptoms and impact of functioning, risks of untreated illness, and the risks associated with the use of medications in pregnancy and lactation. In summary, anxiety disorders in the peripartum period should be recognized and treated promptly.

Perinatal Sleep Problems: Causes, Complications, and Management

Changes in sleep are ubiquitous in the perinatal period and it is important to be able to determine when these changes are significant enough to indicate sleep deficiency associated with increased risk for poor maternal and infant outcomes. Guidelines for identifying sleep deficiency include insomnia symptoms, excessively shortened sleep duration, and perception of insufficient or nonrestful sleep. Causes and complicating factors related to such sleep problems have been well-documented and are used to tailor behavioral and pharmacologic treatments for women who are pregnant or in the early postpartum period.

Preconception Health Risk Factors in Women with and without a History of Military Service

INTRODUCTION

Given the increasing number of women service members and veterans of childbearing age, it is important to understand the preconception risks in this potentially vulnerable population. This study compared the prevalence of modifiable preconception risk factors among women with and without a history of service.

METHODS

Analyses included data from the 2013 and 2014 Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. Preconception risk factors included health behaviors, chronic conditions, and mental health among women of childbearing age. Multivariate logistic regressions were used to compare the adjusted prevalence of each outcome among women with and without a history of service. Interaction terms assessed variation by age and history of service.

RESULTS

Compared with women without a history of service, women with a history of service reported higher prevalence of insufficient sleep (49.6% vs. 36.3%; p < .001) and diagnosed depression (26.5% vs. 21.6%; p < .01). Women with a history of service were overall less likely to have obesity (19.8% vs. 26.5%; p < .001). Age-stratified results suggested that, compared with women without a history of service, women with a history of service were more likely to smoke in the 25 to 34 age group and reported comparable levels of obesity in the 35 to 44 age group.

CONCLUSIONS

Women with a history of service demonstrated a preconception health profile that differs from women without a history of service. It is critical that providers are aware of their patients' military status and potential associated risks.

Non-pharmacological interventions for improving postpartum maternal sleep: A systematic review and meta-analysis

Evidence suggests that poor postpartum sleep quality is a risk factor for the development of postpartum depression. As such, non-pharmacological interventions have been developed to help improve sleep in the postpartum period. The primary aims of this systematic review and meta-analysis were to determine if non-pharmacological interventions improved maternal sleep and to compare the effectiveness of different intervention types. Secondary aims included examining effects on maternal mood and infant sleep. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from their inceptions to September 2017 and found 15 eligible studies. Non-pharmacological sleep interventions were found to improve subjective reports of maternal sleep (Cohen's d = -0.54, 95%CI = -0.88 to -0.19). Massage (Cohen's d = -1.07 95%CI = -1.34 to -0.79) and exercise (Cohen's d = -0.82 95%CI = -1.28 to -0.37) interventions had the largest impact on maternal sleep quality. Positive effects on nocturnal infant sleep were found for interventions overall (Cohen's d = -0.27 95%CI = -0.52 to -0.02) but not for maternal depression (Cohen's d = -0.08 95%CI = -0.28 to 0.12). Despite evidence suggesting improvements in subjective maternal sleep, more research must be conducted on the durability of effects of non-pharmacological interventions using objective measures of sleep quality.

Impact of pregnancy on psychoactive substance use among women with substance use disorders recruited in addiction specialized care centers in France

Pregnancy can be a motivation for decrease in drug abusing but may also represent a period of high vulnerability for relapse. We aimed to assess psychoactive substance use among women with substance use disorders followed in addiction care centers in France. We analyzed data from women aged 15-44 years included in the 'Observation of illegal drugs and misuse of psychotropic medication (OPPIDUM) survey', an annual cross-sectional survey collecting details on psychoactive substances used. Characteristics of women included in 2005-2012 yearly surveys were compared depending on their pregnant or not pregnant status. Factors, including pregnancy, associated with illicit substance use and medication misuse were investigated through logistic regression. The study included 518 pregnant and 6345 nonpregnant women; 85.3% pregnant women were on opioid maintenance therapy (OMT) (vs. 77.1% of nonpregnant). Pregnancy was associated with lower illicit substance use (adjusted OR 0.71 [0.58-0.88]) and with lower medication misuse (0.66 [0.49-0.89]), whereas financial insecurity and living as a couple were associated with increased risk. Raising children was significantly associated with less risk of substance use. Each substance taken separately, the part of women using illicit substance or misusing medication did not differ depending on whether they were pregnant or not, except for heroin (24.5% in pregnant vs. 17.9% nonpregnant; <0.001). This nationwide study provides new insights into psychoactive substance use in a large mixed population of women with drug use disorders. Results outline the challenge of preventing drug use and initiating care strategies with a specific approach on socio-economic environment.

Exercise during early pregnancy is associated with greater sleep continuity

OBJECTIVES/BACKGROUND

Pregnant women report disturbed sleep beginning in early pregnancy. Among nonpregnant populations, exercise has been associated with improved sleep; however, research in pregnant samples has been equivocal. We examined whether varying degrees of exercise were associated with better nocturnal sleep among pregnant women during early gestation.

PARTICIPANTS

172 pregnant women.

METHODS

Self-reported sleep and exercise and objective sleep were collected during early gestation: T1 (10-12 weeks), T2 (14-16 weeks), and T3 (18-20 weeks) from 172 pregnant women. Exercise was categorized into three time-varying groups: 0 metabolic equivalent minutes per week (MET-min/week), 1 to < 500 MET-min/week, or ≥ 500 MET-min/week. Linear mixed-effects models were employed to test hypotheses.

RESULTS

A significant main effect for Time (F[2,254] = 9.77, p < 0.0001) and Time*Exercise group interaction were observed for actigraphic sleep efficiency (aSE) (F[4,569] = 2.73, p = 0.0285). At T2, women who reported ≥ 500 MET-min/week had higher aSE than those who reported 0 MET-min/week. Significant main effects for Exercise Group and Time were observed for actigraphic wake after sleep onset (aWASO; F[2,694] = 3.04, p = 0.0483 and F[2,260] = 3.21, p = 0.0419). aWASO was lowest for those reporting 1 to < 500 MET-min/week (t[701] = 2.35, adjusted p = .0489) and aWASO decreased from T1 to T3 (t[258] = 2.53, adjusted p value = 0.036). Lastly, there was a main effect for Time for the PSQI (F[2,689] = 52.11, p < 0.0001), indicating that sleep quality improved over time.

CONCLUSIONS

Some level of exercise among pregnant women appears to be more advantageous than no exercise at all. Moderate exercise, while still unclearly defined, may be a worthwhile adjunct treatment to combat sleep disturbances during pregnancy.

Sleeping for Two: An Open-Pilot Study of Cognitive Behavioral Therapy for Insomnia in Pregnancy

Insomnia and disturbed sleep are common during pregnancy. This study investigated the effectiveness of group cognitive-behavioral therapy for insomnia (CBT-I) delivered in pregnancy. Thirteen pregnant women with insomnia participated in five weekly CBT-I group sessions. All participants completed the study and provided baseline and follow-up data. Significant reductions in insomnia symptoms and increases in subjective sleep quality were observed over the course of the study. Diary and actigraphy assessments of sleep also changed, such that participants reported less time in bed (TIB), shorter sleep onset latency (SOL), increased sleep efficiency (SE), and increased subjective total sleep time (TST). Additionally, symptoms of depression, pregnancy-specific anxiety, and fatigue all decreased over the course of treatment. Effect sizes ranged from medium to large. CBT-I delivered during pregnancy was associated with significant improvements in sleep and mood. The next step in this area of inquiry is to better establish effectiveness via a randomized controlled trial.

Association of prenatal exposure to benzodiazepines and child internalizing problems: A sibling-controlled cohort study

Background

During pregnancy, many women experience sleep problems and anxiety that require treatment. The long-term safety for the child of maternal benzodiazepine (BZD) and z-hypnotic use during pregnancy remains controversial.

Method

We conducted a cohort and a sibling control study using data from the Norwegian Mother and Child Cohort Study. Data on use of BZD and z-hypnotics, internalizing and externalizing outcomes, and covariates were collected from mothers at gestational weeks 17 and 30 and when children were 0.5, 1.5, and 3 years of age. The total sample consisted of 71,996 children (19,297 siblings) at 1.5 years and 55,081 children (13,779 siblings) at 3 years. Short-term use was defined as use in one pregnancy period only. Long-term use was defined as use in two or more pregnancy periods. Linear full cohort random-effect and sibling-matched fixed-effect regression models were used to compare internalizing and externalizing behavior in children prenatally exposed compared to those unexposed in the full cohort of pregnancies accounting for family clusters, as well as within sibling clusters comparing pregnancies with discordant exposures. Propensity score (PS) adjustment included variables on indication for use (sleep problems, symptoms of anxiety and depression) and other potential confounding factors.

Results

Long-term prenatal exposure to BZD or z-hypnotics was associated with increased internalizing behavior in crude cohort analyses and at age 1.5 years after PS adjustment in sibling-matched fixed-effect models [β 0.60, 95% confidence interval 0.17–0.95]. Analyses on specific drug groups showed that prenatal exposure to BZD-anxiolytics was associated with increased internalizing problems at both 1.5 years [β 0.25, 0.01–0.49] and 3 years [β 0.26, 0.002–0.52] while exposure to z-hypnotics was not associated with any adverse outcomes after adjustment.

Conclusion

The findings suggest a moderate association between BZD-anxiolytic exposure and child internalizing problems that is not likely due to stable familial confounding factors.

Insomnia Treatment Preferences During Pregnancy

OBJECTIVE

To determine pregnant women's preferences for the treatment of insomnia: cognitive behavioral therapy (CBT-I), pharmacotherapy, or acupuncture.

DESIGN

A cross-sectional survey of pregnant women.

SETTING

We recruited participants in person at a low-risk maternity clinic and a pregnancy and infant trade show and invited them to complete an online questionnaire.

PARTICIPANTS

The sample (N = 187) was primarily White (70%), married or common-law married (96%), and on average 31 years of age; the mean gestational age was 28 weeks.

METHODS

Participants read expert-validated descriptions of CBT-I, pharmacotherapy, and acupuncture and then indicated their preferences and perceptions of each approach.

RESULTS

Participants indicated that if they experienced insomnia, they preferred CBT-I to other approaches, χ²(2) = 38.10, p < .001. They rated CBT-I as the most credible treatment (η²_partial = .22, p < .001) and had stronger positive reactions to it than to the other two approaches (η²_partial = .37, p < .001).

CONCLUSION

Participants preferred CBT-I for insomnia during pregnancy. This preference is similar to previously reported preferences for psychotherapy for treatment of depression and anxiety during pregnancy. It is important for clinicians to consider women's preferences when discussing possible treatment for insomnia.

Alcohol consumption, smoking, and drug use in pregnancy: Prevalence and risk factors in Southern Thailand

INTRODUCTION

Substance use during pregnancy contributes to the risk of adverse health outcomes in mothers and children-in utero and during later development. In this study, we investigated the prevalence of substance use and associated factors in pregnant women receiving antenatal care in public hospitals in Thailand.

METHODS

Women (3578) attending 7 antenatal care clinics in Songkhla for the first time during their current pregnancy were interviewed with a structured questionnaire focusing on demographic data, obstetric history, use of alcohol, tobacco, and other substances, and the General Health Questionnaire was administered. The use of substances was confirmed with the ultrarapid version of the Alcohol, Smoking, and Substance Involvement Screening Test and urine tests, which were also administered to 1 in 5 to 10 randomly selected women whose screening results were negative.

RESULTS

Based on self-reports and General Health Questionnaire results, the weighted prevalence of alcohol, tobacco, or illicit substance use and that of "mental health problems" were 5.6% (95% confidence interval [CI], 4.9-6.4) and 29.2% (95% CI, 27.5-30.9), respectively. On the basis of the ultrarapid version of the Alcohol, Smoking, and Substance Involvement Screening Test and urine tests, the prevalence of likely substance use disorder during the 3 months prior to assessment was 1.2% (95% CI, 0.8-1.5) and 7.7% (95% CI, 4.6-10.7), respectively. Factors associated with substance use were religion, unmarried status, unplanned pregnancy, previous abortion, and current mental health problem.

DISCUSSION

Our results emphasize the need for identification of substance use and mental health problems, with the help of questionnaires and biological markers, followed by early intervention.

Tratamento da Insônia em Atenção Primária à Saúde

A insônia é uma das perturbações do sono mais comuns, sendo uma das principais queixas dos pacientes que recorrem aos cuidados médicos. A perturbação de insônia está associada a aumento da morbimortalidade por doenças cardiovasculares, psiquiátricas e acidentes, estando igualmente associada a maior absentismo laboral e maiores custos em saúde. Foram pesquisadas normas de orientação clínica, revisões sistemáticas, meta-análises e estudos originais, publicados entre 2010 e 15 de maio de 2015, relacionados com o tratamento da insônia. O tratamento da insônia pode iniciar-se por terapia cognitivo-comportamental, tratamento farmacológico ou associação dos dois. A terapia cognitivo-comportamental é considerada por várias sociedades médicas como tratamento padrão, sendo que os estudos comprovam a sua eficácia no tratamento da insônia sem ou com comorbilidades e com manutenção a longo prazo dos seus efeitos. Esta compreende múltiplas estratégias, como controle de estímulo, restrição do sono, relaxamento, terapia cognitiva e intenção paradoxal. A farmacoterapia deve ser considerada em situações agudas com necessidade de redução imediata dos sintomas. Os fármacos hipnóticos têm indicação no tratamento da insônia quando os sintomas assumem caráter patológico. Os antidepressivos sedativos, apesar de comumente utilizados, não reúnem evidência da sua eficácia, com exceção da insônia associada a sintomas depressivos ou de ansiedade ou em pacientes com abuso de substâncias. Assim, dada a prevalência de queixas de insônia em atenção primária à saúde, o médico de família deve conhecer a melhor abordagem para o seu tratamento, quer seja farmacológico ou não farmacológico, e os critérios de referenciação. 

Disturbed Sleep and Postpartum Depression

The perinatal period introduces a myriad of changes. One important but often overlooked change is an increased reporting of sleep disturbance. Although casually regarded as a consequence of pregnancy or postpartum, there is emerging evidence implicating significant sleep disturbance, characterized by insomnia symptoms and/or poor sleep quality, with adverse outcomes, such as an increase in depressive symptomatology or the development postpartum depression (PPD). Significant consequences may arise as a result including issues with maternal-infant bonding, effective care for the infant, and behavioral or emotional difficulties in the infant. This review discusses the relevant literature as to how disturbed sleep during pregnancy as well as in the postpartum may increase the risk for PPD.

Evaluation and Management of Behavioral Health Disorders in Women: An Overview of Major Depression, Bipolar Disorder, Anxiety Disorders, and Sleep in the Primary Care Setting

Providers of obstetric and gynecologic care are often the most commonly seen medical providers for adult women, providing primary and reproductive care. Even where psychiatric care is readily available, obstetricians/gynecologists are frequently the front line for recognition, education, and initial management of many mental health problems. In settings where psychiatric treatment is a more scarce resource, obstetricians/gynecologists often are responsible for ongoing treatment of these disorders. This review focuses on the impact of the female reproductive life cycle on the presentation and management of some of the most common behavioral health problems in women: major depression, bipolar disorder, anxiety disorders, and primary sleep disorders.

Insomnia and sleep deficiency in pregnancy

Insomnia and sleep deficiency in pregnancy are very common with most women reporting sleep disturbances during pregnancy. Insomnia and sleep deficiency are also more prevalent as pregnancy progresses, possibly related to pregnancy-related physical symptoms or discomfort. There is increasing evidence indicating that these sleep problems may be associated with adverse maternal and fetal outcomes such as depressive symptoms, increased pain during labor, more Caesarean sections, preterm birth, and low birth weight. Treatment of insomnia remains challenging as some of the more commonly used sleep inducing medications such as benzodiazepines and hypnotic benzodiazepine receptor agonists may be associated with adverse neonatal outcomes. Nonpharmacological treatments such as cognitive behavioral therapy are available but the data in pregnancy is often lacking.