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Kumar N, Saini LK, Gupta R. Diagnosis and management of common sleep disorders during the perinatal period. Int J Gynaecol Obstet 2024. [PMID: 38972008 DOI: 10.1002/ijgo.15776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 06/19/2024] [Accepted: 06/26/2024] [Indexed: 07/08/2024]
Abstract
The perinatal period is a critical phase in a woman's life characterized by significant physical, emotional, and societal changes. Sleep disorders such as insomnia, restless legs syndrome, obstructive sleep apnea, and poor sleep quality have been observed to increase in prevalence during the perinatal period. Given the harmful impact of sleep disturbances on the health of both mother and newborn, it is crucial to diagnose and treat them promptly. There is a paucity of literature on sleep problems during the perinatal period. This narrative review aimed to summarize the existing evidence and provide suggestions for promptly identifying and managing these disorders.
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Affiliation(s)
- Niraj Kumar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, India
- Department of Neurology, All India Institute of Medical Sciences, Bibinagar, India
| | - Lokesh Kumar Saini
- Department of Pulmonary Medicine and Division of Sleep Medicine, All India Institute of Medical Sciences, Rishikesh, India
| | - Ravi Gupta
- Department of Psychiatry and Division of Sleep Medicine, All India Institute of Medical Sciences, Rishikesh, India
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2
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Li Y, Yu H, Shen K, Long J. Women's mental health during late pregnancy: A survey conducted in Shandong Province, China. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2024. [PMID: 38959946 DOI: 10.1055/a-2337-4336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
BACKGROUND The study aimed to investigate the general mental health status and its associated factors in women during late pregnancy. The objective was to provide a scientific basis for developing psychological interventions tailored to this specific population. METHODS The research was conducted from May 2021 to July 2022, involving the recruitment of 200 women attending maternal and child health clinics for their late-pregnancy checkups. Data collection was carried out using a comprehensive approach, involving several validated tools. The participants completed a general demographic and sociological questionnaire along with four standardized psychological assessment scales: the 12-item General Health Questionnaire (GHQ-12), the Athens Insomnia Scale (AIS-8), the Generalized Anxiety Disorder 7 (GAD-7), and the 9-question Patient Health Questionnaire (PHQ-9). A total of 200 valid questionnaires were collected for analysis. RESULTS The study revealed that the overall prevalence of positive detection of general mental health problems in women during late pregnancy was 11%. Significant differences were observed in the positive detection rate of general mental health status based on various factors such as the quality of relationships with husbands, pregnancy intentions, insomnia, anxiety, and depression (p<0.01). Furthermore, participants with general mental health problems displayed notably higher scores on the AIS-8, PHQ-9, and GAD-7 scales compared to those without such problems (p<0.01). Regression analysis indicated that pregnancy intention and PHQ-9 scores were influential factors affecting the general mental health of women during late pregnancy (p<0.05). CONCLUSION The study highlights high rates of general mental health problems during late pregnancy, with unplanned pregnancy and elevated depression scores as key risk factors. Regular mental health screening and targeted interventions are essential to support women during this critical period and enhance the well-being of both mothers and babies.
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Affiliation(s)
- Yijie Li
- Psychological Clinic, Tianjin Anding Hospital, Tianjin, China
| | - Huihui Yu
- Department of outpatient psychology, Tianjin Anding Hospital, Tianjin, China
| | - Kaifang Shen
- Department of Maternal Medicine, Linyi Maternal and Child Health Hospital, Linyi, China
| | - Jing Long
- Tianjin Anding Hospital, Tianjin, China
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3
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Sarvaran K, Abbasalizadeh F, Alaei M, Fathnezhad-Kazemi A. Prevalence of Sleep Disorders and the Effect of Sleep Health Education on Sleep Quality in Pregnant Women With Sleep Disorders. Am J Lifestyle Med 2024; 18:435-444. [PMID: 38737882 PMCID: PMC11082865 DOI: 10.1177/15598276231178746] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Objective Sleep quality affects pregnant women's health and quality of life. The aims of the study were to investigate the prevalence of sleep disorders and the effect of sleep health education on sleep quality in pregnant women with sleep disorders. Methods To examine the frequency of sleep disorders among pregnant women, a cross-sectional study was conducted with an initial enrollment of 370 participants. Subsequently, 162 pregnant women were recruited for a pretest-posttest quasi-experimental design study. The intervention group (n = 82) performed sleep health education for four weeks and the control group (n = 80) received standard care. Sleep quality was assessed with Pittsburgh Sleep Quality. Results The prevalence of sleep disorder was 61.9 percent (CI 95% 56.85-66.69). It was determined that health education improved some sleep quality subscales including subjective sleep quality, sleep latency, sleep duration and habitual sleep efficiency, and sleep disturbances, daytime dysfunction, and global sleep quality. The difference was still significant after adjusting for the PSQI baseline (η2 = .311, P < .001). Conclusion These findings provide evidence of a relatively high prevalence of sleep disorders in pregnancy. Therefore, screening for sleep disorders and providing supportive programs and models to improve sleep quality during pregnancy should be considered as part of prenatal care.
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Affiliation(s)
- Kosar Sarvaran
- Students’ Research committee,
Faculty of Medicine, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran
| | - Fatemeh Abbasalizadeh
- Women’s reproductive health
research center, Tabriz University of Medical
Sciences, Tabriz, Iran
| | - Maede Alaei
- Students’ Research committee,
Faculty of Medicine, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran
| | - Azita Fathnezhad-Kazemi
- Department of Midwifery, Women’s
Reproductive and Mental Health Research center, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran
- Department of Midwifery, Faculty of
Nursing and Midwifery, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran
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Abdurahman A, Dagnew B, Yismaw Gela Y, Akalu Y, Ashenaf Yibeyine B, Diress M, Wako Beko Z, Hasano Kebal A. Sleep Quality and Associated Factors among Pregnant Women Attending Antenatal Care Unit at the Referral Hospitals in Oromia National Regional State, Ethiopia, 2021: A Multicenter Cross-Sectional Study. Behav Sleep Med 2024; 22:247-261. [PMID: 37461301 DOI: 10.1080/15402002.2023.2232499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
INTRODUCTION Poor sleep quality during pregnancy leads to adverse neonatal outcomes such as low birth weight, intrauterine growth retardation, preterm birth, and operative birth. Though it has many consequences, a limited study was conducted on the prevalence and associated factors of poor sleep quality among pregnant women in Ethiopia. OBJECTIVE This study is aimed to determine poor sleep quality and associated factors among pregnant women attending antenatal care units at the selected referral hospitals. METHODS Institution-based cross-sectional study was used from April 20 to June 10, 2021. A The data were collected through systematic random sampling. The Pittsburgh Sleep Quality Index (PSQI) was used to assess the outcome variable based on interview. RESULTS Out of 423, almost 414 participated in the study with a response rate of 97.9%. The prevalence of poor sleep quality was 54.6% (95% CI: 49.7%, 59%). Based on the trimester; about 44.8%, 36.8%, and 64.2% were observed poor sleep quality in the first, second, and third trimesters, respectively. Third trimester [AOR (Adjusted Odd Ratio) = 4.33; 95% CI (Confidence Interval) (1.43, 13.7)], primigravida [AOR = 4.03; 95% CI (2.59, 7.97)], para ≥2 [AOR = 1.95: 95% CI (1.09, 3.48)], depression [AOR = 4.59: 95% CI (2.31, 9.15)], and perceived stress [AOR = 1.15: 95% CI (1.1, 1.22)] were factors significantly associated. CONCLUSION One in every two pregnant women has poor sleep quality. Depression, perceived stress, gestational age, gravida, and parity were identified as associated factors with poor sleep quality. Therefore, healthcare providers should work on screening and counseling for sleep problems during prenatal checkups.
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Affiliation(s)
| | - Baye Dagnew
- Department of Human Physiology, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Ethiopia
| | - Yibeltal Yismaw Gela
- Department of Human Physiology, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Ethiopia
| | - Yonas Akalu
- Department of Human Physiology, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Ethiopia
| | - Baye Ashenaf Yibeyine
- Department of Human Physiology, School of Medicine, Debre Markos University, Debre Markos, Ethiopia
| | - Mengistie Diress
- Department of Human Physiology, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Ethiopia
| | - Zerko Wako Beko
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Abbul Hasano Kebal
- Department of Medical Biochemistry, Madda Walabu University, Bale Goba, Ethiopia
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Murakami K, Ishikuro M, Obara T, Ueno F, Noda A, Onuma T, Matsuzaki F, Kikuchi S, Kobayashi N, Hamada H, Iwama N, Metoki H, Kikuya M, Saito M, Sugawara J, Tomita H, Yaegashi N, Kuriyama S. Social isolation and insomnia among pregnant women in Japan: The Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. Sleep Health 2022; 8:714-720. [PMID: 36229360 DOI: 10.1016/j.sleh.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/25/2022] [Accepted: 08/23/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To estimate the prevalence of insomnia and examine the association between social isolation and insomnia among pregnant women. METHODS This cross-sectional study was part of the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study from 2013 to 2017. Pregnant women were recruited at obstetric clinics and hospitals in Miyagi Prefecture, Japan. We analyzed 17,586 women who completed the questionnaires and were allowed to transcribe medical records. Insomnia was defined as the Athens Insomnia Scale score of ≥6. The Lubben Social Network Scale-abbreviated version was used to assess social isolation (defined as scores <12), and its subscales were used to assess marginal family ties and marginal friendship ties. Multiple logistic regression analyses were conducted to examine the association between social isolation and insomnia during pregnancy, adjusting for age, parity, prepregnancy body mass index, feelings toward pregnancy, education, income, work status, morning sickness, and psychological distress. Multiple logistic regression analyses were also conducted for marginal family ties and marginal friendship ties. RESULTS The prevalence of insomnia in the second trimester was 37.3%. Women who were socially isolated were more likely to have insomnia than women who were socially integrated: the multivariate-adjusted odds ratio (OR) was 1.26 (95% confidence interval [CI], 1.16-1.36). Marginal family ties and marginal friendship ties were also associated with increased risks of insomnia: the multivariate-adjusted ORs were 1.40 (95% CI, 1.25-1.56) and 1.15 (95% CI, 1.07-1.24), respectively. CONCLUSIONS Social isolation from family and friends was associated with increased risks of insomnia among pregnant women.
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Affiliation(s)
- Keiko Murakami
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan.
| | - Mami Ishikuro
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Taku Obara
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Fumihiko Ueno
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Aoi Noda
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Tomomi Onuma
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan
| | - Fumiko Matsuzaki
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan
| | - Saya Kikuchi
- Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Natsuko Kobayashi
- Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hirotaka Hamada
- Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Noriyuki Iwama
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hirohito Metoki
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
| | - Masahiro Kikuya
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Teikyo University School of Medicine, Tokyo, Japan
| | - Masatoshi Saito
- Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Junichi Sugawara
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hiroaki Tomita
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Tohoku University Hospital, Sendai, Miyagi, Japan; International Research Institute of Disaster Science, Tohoku University, Sendai, Miyagi, Japan
| | - Nobuo Yaegashi
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Shinichi Kuriyama
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan; Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; International Research Institute of Disaster Science, Tohoku University, Sendai, Miyagi, Japan
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Liset R, Grønli J, Henriksen RE, Henriksen TEG, Nilsen RM, Pallesen S. 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. PLoS One 2022; 17:e0262799. [PMID: 35089982 PMCID: PMC8797219 DOI: 10.1371/journal.pone.0262799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/15/2021] [Indexed: 11/23/2022] Open
Abstract
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).
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Affiliation(s)
- Randi Liset
- Department of Psychosocial Science, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Janne Grønli
- Department of Biological and Medical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Roger E. Henriksen
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Tone E. G. Henriksen
- Division of Mental Health Care, Fonna Local Health Authority, Valen Hospital, Valen, Norway
| | - Roy M. Nilsen
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Ståle Pallesen
- Department of Psychosocial Science, Faculty of Psychology, University of Bergen, Bergen, Norway
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
- Optentia, The Vaal Triangle Campus of The North-West University, Vanderbijlpark, South-Africa
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Yang JP, Lin RJ, Sun K, Gao LL. Incidence and correlates of insomnia and its impact on health-related quality of life among Chinese pregnant women: a cross-sectional study. J Reprod Infant Psychol 2022:1-12. [PMID: 34989304 DOI: 10.1080/02646838.2021.2020228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aims of this study were to examine the incidence and correlates of insomnia and its impact on health-related quality of life among Chinese pregnant women. METHOD A cross-sectional study was performed from November 2018 to April 2019 in a university-affiliated general hospital in Guangzhou, China. Seven hundred and seventeen pregnant women completed the 36-item Short-Form Health Survey (SF-36), the Self-Rating Anxiety Scale (SAS), the Self-Rating Depression Scale (SDS), and the obstetric and sociodemographic data sheet. FINDINGS 24.3% of the pregnant women suffered from insomnia. Compared with women without insomnia, those with insomnia had a significantly lower health-related quality of life during pregnancy. Maternal age, educational level, occupation, economic status, insurance coverage, gestational age, the woman's relationship with her mother-in-law and anxiety were significantly associated with insomnia among pregnant women. CONCLUSION The incidence of insomnia among pregnant women is high, and insomnia is negatively correlated with health-related quality of life. Appropriate measures and practical therapeutic programmes should be provided to prevent the adverse effects of insomnia in pregnant women with advanced maternal age, lower education, lower economic status, unemployment, lack of insurance coverage, unsatisfied with their relationships with their mothers-in-law, and suffering from anxiety symptoms, especially in the third trimester.
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Affiliation(s)
- Jing-Ping Yang
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Rong-Jin Lin
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Ke Sun
- The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ling-Ling Gao
- School of Nursing, Sun Yat-sen University, Guangzhou, China
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Quin N, Lee JJ, Pinnington DM, Newman L, Manber R, Bei B. Differentiating perinatal Insomnia Disorder and sleep disruption: a longitudinal study from pregnancy to 2 years postpartum. Sleep 2022; 45:6497951. [PMID: 34989808 PMCID: PMC9013000 DOI: 10.1093/sleep/zsab293] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 12/07/2021] [Indexed: 01/07/2023] Open
Abstract
STUDY OBJECTIVES Insomnia Disorder diagnoses require persistent sleep complaints despite "adequate sleep opportunity." Significant Perinatal Sleep Disruption makes this diagnosis challenging. This longitudinal study distinguished between Insomnia Disorder and Perinatal Sleep Disruption and their sleep and mental health correlates. METHODS One hundred sixty-three nulliparous females (age M ± SD = 33.35 ± 3.42) participating in a randomized controlled trial repeated the Insomnia Disorder module of the Duke Structured Interview for Sleep Disorders and Patient-Reported Outcome Measurement Information System measures for sleep and mental health at 30- and 35-weeks' gestation, and 1.5, 3, 6, 12, and 24 months postpartum (944 interviews, 1009 questionnaires completed). We compared clinical features when Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Insomnia Disorder criteria (without the Duration criterion) were: (1) met (Insomnia Disorder), (2) not met only because of the sleep opportunity criteria (Perinatal Sleep Disruption), and (3) not met due to other criteria (Low Complaint). RESULTS Proportions of Insomnia Disorder were 16.0% and 19.8% during early and late third trimester, and ranged 5.3%-11.7% postpartum. If the sleep opportunity criteria were not considered, rates of Insomnia would be 2-4 times higher (21.4%-40.4%) across time-points. Mixed-effects models adjusting for covariates showed that compared to Low Complaint, both Insomnia Disorder and Perinatal Sleep Disruption scored significantly higher on insomnia and sleep disturbance scales, sleep effort, and sleep-related impairments (p values < .01), but depression and anxiety were comparable (p values > .12). CONCLUSION Assessing sleep complaints without considering sleep opportunities can result in over-diagnosis of Insomnia Disorder in the perinatal periods. Insomnia Disorder and Perinatal Sleep Disruption were both associated with adverse sleep and mood outcomes, and need to be carefully differentiated and appropriately addressed. Clinical Trial Registration: The SEED Project (Sleep, Eat, Emotions, and Development): A randomized controlled pilot study of a perinatal sleep intervention on sleep and wellbeing in mothers and infants. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371634, Australian New Zealand Clinical Trials Registry: ACTRN12616001462471.
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Affiliation(s)
- Nina Quin
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia,Women’s Mental Health Service, Royal Women’s Hospital, Parkville, VIC, Australia
| | - Jin Joo Lee
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia,Women’s Mental Health Service, Royal Women’s Hospital, Parkville, VIC, Australia
| | - Donna M Pinnington
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia,Women’s Mental Health Service, Royal Women’s Hospital, Parkville, VIC, Australia
| | - Louise Newman
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | - Rachel Manber
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA
| | - Bei Bei
- Corresponding author. Bei Bei, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, 18 Innovation Walk, Clayton Campus, VIC 3800, Australia.
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Tan XYJ, Choong SYX, Cheng LJ, Lau Y. Relaxation interventions for improving sleep outcomes in perinatal women: A systematic review and meta-analysis of randomized controlled trials. Midwifery 2021; 103:103151. [PMID: 34607056 DOI: 10.1016/j.midw.2021.103151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/24/2021] [Accepted: 09/16/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sleep problem is common amongst perinatal women, and stress may trigger and intensify sleep problems in a vicious cycle. Relaxation interventions are gradually being adopted to improve sleep quality in various populations, but little is known about their effectiveness in perinatal women. OBJECTIVE To evaluate the effects of relaxation interventions on sleep outcomes amongst all perinatal women aged 18 and above, and identify the essential type, regime and approach in designing relaxation intervention. DESIGN Systematic review and meta-analysis of 11 studies among 1046 perinatal women. DATA SOURCES We searched Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica dataBASE, PsycINFO, ProQuest Dissertations and Theses, PubMed and Web of Science from their inception until December 15, 2019. REVIEW METHODS Studies were assessed for clinical and statistical heterogeneity and considered for meta-analysis. Comprehensive Meta-analysis and The Cochrane Risk of Bias tool were used for meta-analyses and assessing of risk of bias, respectively. RESULTS A total of 6346 records were identified, and 11 randomised control trials were selected. Significantly large effects were found in relaxation interventions in improving sleep quality (Cohen's d = 2.55), disturbance (Cohen's d = 1.52), latency (Cohen's d = 1.82) and duration (Cohen's d = 1.14) when compared with those in the control groups. Subgroup analyses showed that antenatal women who performed progressive muscle relaxation (PMR) by themselves for preventive function and long-term practice showed improved sleep quality compared with their counterparts. CONCLUSION PMR is preferable as a supplementary intervention to current existing antenatal care. The grade of the overall evidence of the outcomes ranged from very low to low. IMPLICATIONS FOR PRACTICE The meta-analysis addressed the effect of relaxation interventions on sleep outcomes amongst perinatal women. Relaxation interventions may effectively improve sleep quality, disturbance, latency and duration amongst perinatal women early in antenatal period. However, further well-designed trials in large samples are required.
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Affiliation(s)
- Xing Yee Jolyn Tan
- Department of Nursing, Khoo Teck Puat Hospital, Yishun Health, National Healthcare Group, Singapore.
| | - Shanise Yi Xin Choong
- Department of Nursing, Khoo Teck Puat Hospital, Yishun Health, National Healthcare Group, Singapore.
| | - Ling Jie Cheng
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
| | - Ying Lau
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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MacKinnon AL, Madsen JW, Dhillon A, Keys E, Giesbrecht GF, Williamson T, Metcalfe A, Campbell T, Mrklas KJ, Tomfohr-Madsen L. Sleeping for two: study protocol for a randomized controlled trial of cognitive behavioral therapy for insomnia in pregnant women. Trials 2021; 22:532. [PMID: 34384459 PMCID: PMC8358257 DOI: 10.1186/s13063-021-05498-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Insomnia and sleep disturbances are common in pregnancy and have potentially significant consequences for both maternal and infant health. There is limited research examining the effectiveness of cognitive behavioral therapy for insomnia (CBT-I) during pregnancy. With increased distress and limited access to services during the COVID-19 pandemic, there is also an unprecedented need for telehealth delivery of treatment programs for pregnant women. The aims of this trial are to evaluate the impact of the Sleeping for Two adaptation of CBT-I in pregnancy (in-person or telehealth) versus treatment as usual (TAU) in reducing symptoms of insomnia (primary outcome), as well as increasing gestational length and reducing symptoms of depression (secondary outcomes). METHODS A two-arm, single-blinded, parallel group randomized controlled trial (RCT) design with repeated measures will be used to evaluate the impact of CBT-I compared to TAU among a sample of 62 pregnant women, enrolled between 12 and 28 weeks of gestation, who self-identify as experiencing insomnia. Five weekly individual sessions of CBT-I will be delivered in person or via telehealth depending on physical distancing guidelines. Assessment of insomnia diagnosis by structured interview, self-reported insomnia symptom severity and sleep problems, and sleep quantity and quality as measured by a daily diary and actigraphy will occur at 12-28 weeks of pregnancy (T1), 1 week post-treatment (T2), and 6 months postpartum (T3). DISCUSSION CBT-I delivered in pregnancy has the potential to reduce symptoms of insomnia and depression and could lead to reduced risk of preterm birth, all of which can minimize risk of negative maternal and child health and developmental consequences in the short (e.g., infant death) and long terms (e.g., developmental delays). This RCT builds on a successful open pilot trial conducted by our team and will provide further evaluation of a novel evidence-based treatment for pregnancy-related insomnia, which can be widely disseminated and used to treat individuals that are most in need of intervention. Findings will enhance understanding of pregnancy-related sleep problems, as well as means by which to improve the health and sleep of mothers and their children. TRIAL REGISTRATION ClinicalTrials.gov NCT03918057. Registered on 17 April 2019.
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Sleep, evening light exposure and perceived stress in healthy nulliparous women in the third trimester of pregnancy. PLoS One 2021; 16:e0252285. [PMID: 34081723 PMCID: PMC8174691 DOI: 10.1371/journal.pone.0252285] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 05/12/2021] [Indexed: 12/25/2022] Open
Abstract
Objective Sleep disturbances are common in pregnancy, and the prevalence increases during the third trimester. The aim of the present study was to assess sleep patterns, sleep behavior and prevalence of insomnia in pregnant women in the third trimester, by comparing them to a group of non-pregnant women. Further, how perceived stress and evening light exposure were linked to sleep characteristics among the pregnant women were examined. Methods A total of 61 healthy nulliparous pregnant women in beginning of the third trimester (recruited from 2017 to 2019), and 69 non-pregnant women (recruited in 2018) were included. Sleep was monitored by actigraphy, sleep diaries and the Bergen Insomnia Scale. The stress scales used were the Relationship Satisfaction Scale, the Perceived Stress Scale and the Pre-Sleep Arousal Scale. Total white light exposure three hours prior to bedtime were also assessed. Results The prevalence of insomnia among the pregnant women was 38%, with a mean score on the Bergen Insomnia Scale of 11.2 (SD = 7.5). The corresponding figures in the comparing group was 51% and 12.3 (SD = 7.7). The pregnant women reported lower sleep efficiency (mean difference 3.8; 95% CI = 0.3, 7.3), longer total sleep time derived from actigraphy (mean difference 59.0 minutes; 95% CI = 23.8, 94.2) and higher exposure to evening light (mean difference 0.7; 95% CI = 0.3, 1.2), compared to the non-pregnant group. The evening light exposure was inversely associated with total sleep time derived from actigraphy (B = -8.1; 95% CI = -14.7, -1.5), and an earlier midpoint of sleep (B = -10.3, 95% CI = -14.7, -5.9). Perceived stressors were unrelated to self-reported and actigraphy assessed sleep. Conclusion In healthy pregnant participants sleep in the third trimester was preserved quite well. Even so, the data suggest that evening light exposure was related to shorter sleep duration among pregnant women.
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Demographic, Pregnancy-Related, and Health-Related Factors in Association with Changes in Sleep Among Pregnant Women with Overweight or Obesity. Int J Behav Med 2021; 28:200-206. [PMID: 32378048 DOI: 10.1007/s12529-020-09887-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Women with prepregnancy overweight/obesity are at high risk for obstetric complications and cardiometabolic disease. Poorer sleep quality is associated with obesity in non-pregnant individuals and, during pregnancy, poor sleep predicts negative obstetric and health outcomes. This study examined sleep patterns among women with overweight/obesity and factors associated with different sleep trajectories during pregnancy. METHODS Women (N = 146, 17-40 years old) with a prepregnancy body mass index ≥ 25 kg/m2 were recruited during early pregnancy. Participants reported demographic information and completed the Pittsburgh Sleep Quality Index (PSQI) at up to six monthly assessments, with the first assessment occurring between 12 and 20 weeks gestation and the final assessment between 35 weeks gestation and delivery. PSQI scores > 5 indicate "poor sleep." RESULTS On average, women's PSQI scores were 6.66 ± 3.58 in the first half of pregnancy and were significantly higher (worse) at the end of pregnancy (t(644) = 4.55, p < 0.001), with the greatest change occurring in the third trimester (t(636.3) = 3.72, p < 0.001). Women who currently smoked had poorer sleep than women who did not currently smoke (t(1) = 2.29, p = 0.02). Prepregnancy weight status, age, parity, race, education, and income were not significantly associated with sleep changes (t(1) < 1.76, ps > 0.08). The percentage of women with PSQI scores > 5 (the threshold for poor sleep quality) was 37-63% across assessments, with the greatest increase occurring during the third trimester (t(633) = 2.92, p = 0.004). CONCLUSIONS Sleep quality worsens during the third trimester and is associated with current smoking. Future studies of sleep during pregnancy should examine health outcomes among women with overweight/obesity and early intervention to mitigate sleep disturbances as pregnancy progresses.
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Pietikäinen JT, Härkänen T, Polo-Kantola P, Karlsson H, Paunio T, Karlsson L, Paavonen EJ. Estimating the cumulative risk of postnatal depressive symptoms: the role of insomnia symptoms across pregnancy. Soc Psychiatry Psychiatr Epidemiol 2021; 56:2251-2261. [PMID: 33961078 PMCID: PMC8558280 DOI: 10.1007/s00127-021-02101-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 04/23/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Insomnia symptoms during late pregnancy are a known risk for postnatal depressive symptoms (PDS). However, the cumulative effect of various risk factors throughout pregnancy has not been explored. Our aim was to test how various insomnia symptoms (sleep latency, duration, quality, frequent night awakenings, early morning awakenings) and other risk factors (e.g., history of depression, symptoms of depression and anxiety, as well as sociodemographic factors) in early, mid-, and late pregnancy predict PDS. METHODS Using data from the FinnBrain Birth Cohort Study and logistic regression analyses, we investigated the associations of distinct insomnia symptoms at gw 14, 24, and 34 with depressive symptoms (Edinburgh Postnatal Depression Scale score ≥ 11) 3 months postnatally. We also calculated separate and combined predictive models of PDS for each pregnancy time point and reported the odds ratios for each risk group. RESULTS Of the 2224 women included in the study, 7.1% scored EPDS ≥ 11 3 months postnatally. Our predictive models indicated that sleep latency of ≥ 20 min, anxiety in early pregnancy, and insufficient sleep during late pregnancy predicted the risk of PDS. Furthermore, we found highly elevated odds ratios in early, mid-, and late pregnancy for women with multiple PDS risk factors. CONCLUSION Screening of long sleep latency and anxiety during early pregnancy, in addition to depression screening, could be advisable. Odds ratios of risk factor combinations demonstrate the magnitude of cumulating risk of PDS when multiple risk factors are present.
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Affiliation(s)
- Johanna T. Pietikäinen
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland ,Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Mannerheimintie 166, P. O. Box 30, 00271 Helsinki, Finland
| | - Tommi Härkänen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Mannerheimintie 166, P. O. Box 30, 00271 Helsinki, Finland
| | - Päivi Polo-Kantola
- Department of Obstetrics and Gynaecology, Turku University Hospital, Turku University, Turku, Finland ,Department of Pulmonary Diseases and Allergology, Sleep Research Centre, University of Turku, Turku, Finland
| | - Hasse Karlsson
- Department of Clinical Medicine, The FinnBrain Birth Cohort Study, Turku Brain and Mind Center, University of Turku, Turku, Finland ,Department of Psychiatry, Turku University Hospital and University of Turku, Turku, Finland ,Centre for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland
| | - Tiina Paunio
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Mannerheimintie 166, P. O. Box 30, 00271 Helsinki, Finland ,Department of Psychiatry and SleepWell Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Linnea Karlsson
- Department of Clinical Medicine, The FinnBrain Birth Cohort Study, Turku Brain and Mind Center, University of Turku, Turku, Finland
| | - E. Juulia Paavonen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Mannerheimintie 166, P. O. Box 30, 00271 Helsinki, Finland ,Department of Child Psychiatry, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Abstract
PURPOSE OF REVIEW Sleep disturbances are increasing in prevalence in North America. There is growing evidence that poor sleep quality and short sleep duration may adversely affect circadian rhythms, which in turn may affect female reproduction. The objective of this review is to evaluate recent literature on the association between sleep disturbances and female reproduction. RECENT FINDINGS There is accumulating evidence that sleep quality and duration are important for female reproduction, but epidemiologic research is limited. Recent studies provide suggestive evidence that sleep disorders are associated with increased menstrual irregularity, subfertility/infertility, and poor pregnancy and birth outcomes. Mechanisms underlying these associations are likely to be multifactorial and complex. In addition to genetics, circadian disruption may impact reproductive outcomes through dysregulation of the hypothalamic-pituitary-adrenal axis, insulin resistance, oxidative stress, and systemic inflammation. Recommendations for future studies include: use of prospective study designs; assessment of populations not already experiencing reproductive disorders; more detailed and accurate assessments of sleep such as validated self-reported measures or objective sleep measures (e.g. actigraphy); comprehensive assessment of potential confounders and mediators; and elucidation of biologic mechanisms. SUMMARY There is a growing body of literature showing evidence that sleep disturbances influence female reproduction, although further epidemiologic research is needed.
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Affiliation(s)
- Sydney Kaye Willis
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
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15
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Wang WJ, Hou CL, Jiang YP, Han FZ, Wang XY, Wang SB, Ng CH, Jia FJ. Prevalence and associated risk factors of insomnia among pregnant women in China. Compr Psychiatry 2020; 98:152168. [PMID: 32105909 DOI: 10.1016/j.comppsych.2020.152168] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/10/2020] [Accepted: 02/12/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Insomnia is common during pregnancy but the prevalence and risk factors of insomnia in Chinese women during pregnancy is not well studied. This study aimed to examine the prevalence of insomnia and its risk factors in Chinese women during pregnancy. METHODS In this cross sectional study, 436 Chinese pregnant women with Insomnia Severity Index (ISI) ≥ 8 were clinically assessed using the insomnia criteria based on the combination of DSM-IV (Diagnostic and Statistical Manual-4th Edition) and ICD-10 (International Classification of Dieases, 10th Edition). Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), Pregnancy Pressure Scale (PPS), Perceived physical discomfort level and number, Epworth Sleepiness Scale (ESS), and a general socio-demographic questionnaire were administered. RESULTS The results showed that about 20% of the pregnant women met the strict diagnosis criteria of insomnia. Independent-samples t-test revealed that several risk factors were correlated with the group with insomnia (N = 84) compared to the group without insomnia (N = 352). Binary Logistic regression analysis found that more significant bed partner influence (OR = 1.92, 95% CI: 1.03-3.60), depressive symptoms (OR = 1.07, 95% CI: 1.00-1.14), daytime sleepiness (OR = 1.07, 95% CI: 1.01-1.14), subjective somatic discomfort (OR = 2.27, 95% CI: 1.11-4.65), kinds of somatic discomfort (OR = 1.14, 95% CI: 1.03-1.27) and later gestation (OR = 1.05, 95% CI: 1.01-1.09) were significantly associated with insomnia. CONCLUSION In this cohort of Chinese pregnant women, about a fifth of women suffered from clinically significant insomnia. Measures to prevent the adverse effects of insomnia should be provided to pregnant women with depressive symptoms, Sleep disturbance of the bed partner, excessive daytime sleepiness and somatic discomfort, especially late in gestation.
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Affiliation(s)
- Wen-Jing Wang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Cai-Lan Hou
- Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China.
| | - Yan-Ping Jiang
- Department of Obstetrics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Feng-Zhen Han
- Department of Obstetrics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Xiao-Yun Wang
- Department of Obstetrics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Shi-Bin Wang
- Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - C H Ng
- Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Fu-Jun Jia
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China.
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Barghouthi T, Lemley R, Figurelle M, Bushnell C. Epidemiology of neurologic disease in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 171:119-141. [PMID: 32736746 DOI: 10.1016/b978-0-444-64239-4.00006-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Many neurologic diseases in women are influenced by the physiologic and hormonal changes of pregnancy, and pregnancy itself poses challenges in both treatment and evaluation of these conditions. Some diseases, such as epilepsy and multiple sclerosis, have a high enough prevalence in the young female population to support robust epidemiologic data while many other neurologic diseases, such as specific myopathies and muscular dystrophies, have a low prevalence, with data limited to case reports and small case series. This chapter features epidemiologic information regarding a breadth of neurologic conditions, including stroke, epilepsy, demyelinating disease, peripheral neuropathies, migraine, sleep-disordered breathing, and meningioma, in women in the preconception, pregnancy, and postpartum stages.
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Affiliation(s)
- Tamara Barghouthi
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Regan Lemley
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Morgan Figurelle
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Cheryl Bushnell
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States.
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Abstract
Pregnancy is associated with a number of physiologic changes in the body including hormonal, anatomical, and mechanical. These changes alter many physiologic functions including sleep. The literature suggests that a number of women develop changes in duration, pattern, and quality of sleep during pregnancy. In addition, these changes also pave the way for expression of sleep disorders (e.g., insomnia, obstructive sleep apnea, and restless legs syndrome). Change in sleep and appearance of sleep disorders not only influence pregnant women, but also have negative influences on the fetus and outcomes of pregnancy. However, optimal management of these disorders may reverse adverse consequences. In this chapter, risk factors, clinical presentation, and management of insomnia, obstructive sleep apnea, and restless legs syndrome during pregnancy are discussed in view of the available literature.
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Affiliation(s)
- Ravi Gupta
- Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, India.
| | - Vikram Singh Rawat
- Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, India
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Lahti-Pulkkinen M, Mina TH, Riha RL, Räikkönen K, Pesonen AK, Drake AJ, Denison FC, Reynolds RM. Maternal antenatal daytime sleepiness and child neuropsychiatric and neurocognitive development. Psychol Med 2019; 49:2081-2090. [PMID: 30293538 DOI: 10.1017/s003329171800291x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The prevalence of sleep problems among pregnant women is over 50%, and daytime sleepiness is among the most common sleep problems. Previous studies have associated antenatal sleep problems with adverse maternal health and neonatal outcomes, but the consequences of antenatal sleep problems and particularly daytime sleepiness on child psychological development have not been assessed prospectively. METHODS In this prospective cohort study including 111 mother-child dyads, we examined the associations of maternal daytime sleepiness during pregnancy, assessed at 17 and 28 weeks of gestation using the Epworth Sleepiness Scale, with child neuropsychiatric problems and neuropsychological development, assessed with mother-rated questionnaires and individually administered neuropsychological tests, at child age 2.6-5.7 years (mean = 4.3 years). RESULTS Independently of sociodemographic and perinatal covariates and maternal depressive and anxiety symptoms during and/or after pregnancy, maternal antenatal daytime sleepiness was associated with increased total [unstandardized regression coefficient (B) = 0.25 standard deviation (s.d.) units; 95% confidence interval (CI) 0.01-0.48] and internalizing (B = 0.25 s.d.s: 95% CI 0.01-0.49) psychiatric problems and ADHD symptoms (B = 0.27 s.d.s: 95% CI 0.04-0.50) in children, and with poorer executive function, particularly in the areas of attention, working memory and inhibitory control (B = -0.39 s.d.s: 95% CI -0.69 to -0.10). CONCLUSIONS Maternal antenatal daytime sleepiness carries adverse consequences for offspring psychological development. The assessment of sleep problems may be an important addition to standard antenatal care.
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Affiliation(s)
- M Lahti-Pulkkinen
- British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
- Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - T H Mina
- British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- Tommy's Centre for Maternal and Fetal Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, Scotland, UK
| | - R L Riha
- Department of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - K Räikkönen
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
| | - A K Pesonen
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
- Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - A J Drake
- British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - F C Denison
- Tommy's Centre for Maternal and Fetal Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, Scotland, UK
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, Scotland, UK
| | - R M Reynolds
- British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- Tommy's Centre for Maternal and Fetal Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, Scotland, UK
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Willis SK, Hatch EE, Wesselink AK, Rothman KJ, Mikkelsen EM, Wise LA. Female sleep patterns, shift work, and fecundability in a North American preconception cohort study. Fertil Steril 2019; 111:1201-1210.e1. [PMID: 30987736 DOI: 10.1016/j.fertnstert.2019.01.037] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/24/2019] [Accepted: 01/30/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To prospectively evaluate the association between female sleep patterns, shift work, and fecundability. DESIGN Web-based preconception cohort study, Pregnancy Study Online (PRESTO). SETTING Not applicable. PATIENT(S) North American Women aged 21-45 years attempting pregnancy. INTERVENTION(S) Not applicable. MAIN OUTCOME MEASURE(S) At baseline, self-reported average sleep duration per 24-hour period in the previous month, the frequency of trouble sleeping within the last 2 weeks (as measured by the Major Depression Inventory), and shift work patterns. Pregnancy status determined by follow-up questionnaires completed every 8 weeks for up to 12 months or until conception. RESULT(S) The analyses were restricted to 6,873 women attempting pregnancy for ≤6 months at enrollment from June 2013 through September 2018. We used proportional probabilities regression models to estimate fecundability ratios (FRs) and 95% confidence intervals (CIs), adjusting for potential confounders. Relative to 8 hours of sleep per day, FRs for <6, 6, 7, and ≥9 hours of sleep/day were 0.89 (95% CI, 0.75-1.06), 0.95 (95% CI, 0.86-1.04), 0.99 (95% CI, 0.92-1.06), and 0.96 (95% CI, 0.84-1.10), respectively. Compared with no trouble sleeping, FRs for trouble sleeping <50% of the time or trouble sleeping >50% of the time were 0.93 (95% CI, 0.88-1.00) and 0.87 (95% CI, 0.79-0.95), respectively. The results were slightly stronger among women with higher depressive symptoms and perceived stress levels. There was no association between shift work and fecundability. CONCLUSION(S) Trouble sleeping at night was associated with modestly reduced fecundability. A weaker inverse association was observed between shorter sleep duration and fecundability.
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Affiliation(s)
- Sydney Kaye Willis
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts.
| | - Elizabeth Elliott Hatch
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
| | - Amelia Kent Wesselink
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
| | - Kenneth Jay Rothman
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts; RTI International, Research Triangle Park, North Carolina
| | | | - Lauren Anne Wise
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
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Perkins A, Einion A. Pregnant pause: should we screen for sleep disordered breathing in pregnancy? Breathe (Sheff) 2019; 15:36-44. [PMID: 30838058 PMCID: PMC6395990 DOI: 10.1183/20734735.0343-2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Physiological and hormonal changes in pregnancy can contribute towards sleep disordered breathing in pregnant women (SDBP). When present, SDBP increases the risk of several adverse maternal and fetal outcomes independent of factors such as age, weight and pre-existing maternal comorbidities. SDBP is underdiagnosed and may be hard to recognise because the presentation can be difficult to differentiate from normal pregnancy and the severity may change over the course of gestation. Timely intervention seems likely to help reduce adverse outcomes, but the relative benefits of intervention are still unclear. The definition of what constitutes a sleep-related breathing “disorder” in pregnancy may be different to the general population and so traditional thresholds for intervention may not be relevant in pregnancy. Any modifications to the disease definition in this group, or implementation of more intensive screening, may result in overdiagnosis. Further research is needed to help clinicians evaluate the balance of benefits and harms in this process. Until this is clearer there is a strong imperative for shared decision making in screening and treatment decisions, and screening programmes should be monitored to assess whether improved outcomes can be achieved at the healthcare system level. Untreated sleep disordered breathing in pregnancy poses risks to maternal and fetal wellbeing, but thresholds for and effectiveness of intervention are unclear. Clinicians should use shared decision making for screening and treatment decisions.http://ow.ly/N0oN30noWnx
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Affiliation(s)
- Alex Perkins
- Respiratory and Sleep Physiology, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Alys Einion
- Midwifery and Reproductive Health, College of Human and Health Sciences, Swansea University, Swansea, UK
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Tomfohr-Madsen LM, Clayborne ZM, Rouleau CR, Campbell TS. Sleeping for Two: An Open-Pilot Study of Cognitive Behavioral Therapy for Insomnia in Pregnancy. Behav Sleep Med 2017; 15:377-393. [PMID: 27124405 DOI: 10.1080/15402002.2016.1141769] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Lianne M Tomfohr-Madsen
- a Department of Psychology , University of Calgary , Calgary , Alberta , Canada.,b Alberta Children's Hospital Research Institute for Child and Maternal Health , Calgary , Alberta , Canada.,c Department of Pediatrics , Alberta Children's Hospital , Calgary , Alberta , Canada
| | - Zahra M Clayborne
- a Department of Psychology , University of Calgary , Calgary , Alberta , Canada
| | - Codie R Rouleau
- a Department of Psychology , University of Calgary , Calgary , Alberta , Canada
| | - Tavis S Campbell
- a Department of Psychology , University of Calgary , Calgary , Alberta , Canada
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Khayamim N, Bahadoran P, Mehrabi T. Relationship between fatigue and sleepiness with general health of mothers in the postpartum period. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2016; 21:385-90. [PMID: 27563322 PMCID: PMC4979262 DOI: 10.4103/1735-9066.185580] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background: Fatigue and changes in sleep patterns are one of the impressive features in the first year after birth, which have negative effects on work, family life, and social relationships. Therefore, the objective of this research was to investigate the relationship between fatigue and Stanford sleepiness with the general health of mothers in the postpartum period. Materials and Methods: The current research is a descriptive correlational study which was performed on 190 mothers between 2 and 24 postpartum weeks, referring to the health centers of Isfahan in 2014. All mothers meeting the inclusion criteria were selected through cluster purposive sampling. Data were collected by use of four questionnaires including profile and fertility, fatigue, Stanford sleepiness, and general health. Data were analyzed by statistical tests at a significance level of ≤0.05. Results: The results showed that 5.3%, 59.5%, and 35.3% of subjects had mild, moderate, and severe fatigue, respectively. In addition, 26.3% of women showed a public health disorder, and according to Stanford sleepiness, 20.5% of subjects had sleepiness. The statistical results indicated that there were significant relationships between fatigue (P ≤ 0.001, r = 0.52) and Stanford sleepiness (P = 0.04, r = 0.14), and mothers’ general health. Conclusions: According to prevalence of fatigue and sleepiness in the postpartum period and its relationship with maternal health, application of sleep health education and appropriate counseling during pregnancy and after delivery is recommended to prevent mothers’ mental complications in order to achieve a safe pregnancy.
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Affiliation(s)
- Nafiseh Khayamim
- Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parvin Bahadoran
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Tayebeh Mehrabi
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
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Gelaye B, Zhong QY, Barrios YV, Redline S, Drake CL, Williams MA. Psychometric Evaluation of the Ford Insomnia Response to Stress Test (FIRST) in Early Pregnancy. J Clin Sleep Med 2016; 12:579-87. [PMID: 26857055 DOI: 10.5664/jcsm.5696] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 11/25/2015] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To evaluate the construct validity and factor structure of the Spanish-language version of the Ford Insomnia Response to Stress Test questionnaire (FIRST-S) when used in early pregnancy. METHODS A cohort of 647 women were interviewed at ≤ 16 weeks of gestation to collect information regarding lifestyle, demographic, and sleep characteristics. The factorial structure of the FIRST-S was tested through exploratory and confirmatory factor analyses (EFA and CFA). Internal consistency and construct validity were also assessed by evaluating the association between the FIRST-S with symptoms of depression, anxiety, and sleep quality. Item response theory (IRT) analyses were conducted to complement classical test theory (CTT) analytic approaches. RESULTS The mean score of the FIRST-S was 13.8 (range: 9-33). The results of the EFA showed that the FIRST-S contained a one-factor solution that accounted for 69.8% of the variance. The FIRST-S items showed good internal consistency (Cronbach α = 0.81). CFA results corroborated the one-factor structure finding from the EFA; and yielded measures indicating goodness of fit (comparative fit index of 0.902) and accuracy (root mean square error of approximation of 0.057). The FIRST-S had good construct validity as demonstrated by statistically significant associations of FIRST-S scores with sleep quality, antepartum depression and anxiety symptoms. Finally, results from IRT analyses suggested excellent item infit and outfit measures. CONCLUSIONS The FIRST-S was found to have good construct validity and internal consistency for assessing vulnerability to insomnia during early pregnancy.
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Affiliation(s)
- Bizu Gelaye
- Department of Epidemiology, Harvard School of Public Health, Boston, MA
| | - Qiu-Yue Zhong
- Department of Epidemiology, Harvard School of Public Health, Boston, MA
| | - Yasmin V Barrios
- Department of Epidemiology, Harvard School of Public Health, Boston, MA
| | - Susan Redline
- Department of Epidemiology, Harvard School of Public Health, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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24
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Zaremba S, Mueller N, Heisig AM, Shin CH, Jung S, Leffert LR, Bateman BT, Pugsley LJ, Nagasaka Y, Duarte IM, Ecker JL, Eikermann M. Elevated upper body position improves pregnancy-related OSA without impairing sleep quality or sleep architecture early after delivery. Chest 2016; 148:936-944. [PMID: 25905714 DOI: 10.1378/chest.14-2973] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND During pregnancy, upper airway resistance is increased, predisposing vulnerable women to pregnancy-related OSA. Elevation of the upper body increases upper airway cross-sectional area (CSA) and improves severity of OSA in a subgroup of nonpregnant patients (positional-dependent sleep apnea). We tested the hypothesis that elevated position of the upper body improves OSA early after delivery. METHODS Following institutional review board approval, we conducted a randomized, crossover study on two postpartum units of Massachusetts General Hospital. Women during the first 48 h after delivery were included. Polysomnography was performed in nonelevated and 45° elevated upper body position. Upper airway CSA was measured by acoustic pharyngometry in nonelevated, 45° elevated, and sitting body position. RESULTS Fifty-five patients were enrolled, and measurements of airway CSA obtained. Thirty patients completed polysomnography in both body positions. Elevation of the upper body significantly reduced apnea-hypopnea index (AHI) from 7.7 ± 2.2/h in nonelevated to 4.5 ± 1.4/h in 45° elevated upper body position (P = .031) during sleep. Moderate to severe OSA (AHI > 15/h) was diagnosed in 20% of postpartum patients and successfully treated by elevated body position in one-half of them. Total sleep time and sleep architecture were not affected by upper body elevation. Change from nonelevated to sitting position increased inspiratory upper airway CSA from 1.35 ± 0.1 cm2 to 1.54 ± 0.1 cm2 during wakefulness. Position-dependent increase in CSA and decrease in AHI were correlated (r = 0.42, P = .022). CONCLUSIONS Among early postpartum women, 45° upper body elevation increased upper airway CSA and mitigated sleep apnea. Elevated body position might improve respiratory safety in women early after delivery. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01719224; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Sebastian Zaremba
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Sleep Medicine, Department of Neurology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Noomi Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Anne M Heisig
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Christina H Shin
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Stefanie Jung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Department of Pediatric Surgery, DRK-Kinderklinik Siegen, Teaching Hospital of Philipps University, Marburg, Germany; Department of Pediatric Urology, DRK-Kinderklinik Siegen, Teaching Hospital of Philipps University, Marburg, Germany
| | - Lisa R Leffert
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Brian T Bateman
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lori J Pugsley
- Department of Obstetrics and Gynecology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Yasuko Nagasaka
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ingrid Moreno Duarte
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Jeffrey L Ecker
- Department of Obstetrics and Gynecology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Department of Anesthesia and Critical Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
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25
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Tzeng YL, Chen SL, Chen CF, Wang FC, Kuo SY. Sleep Trajectories of Women Undergoing Elective Cesarean Section: Effects on Body Weight and Psychological Well-Being. PLoS One 2015; 10:e0129094. [PMID: 26066326 PMCID: PMC4466331 DOI: 10.1371/journal.pone.0129094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/05/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND After cesarean section (CS), women may be at great risk for sleep disturbance, but little is known about temporal changes in their sleep patterns and characteristics. We had two aims: 1) to identify distinct classes of sleep-disturbance trajectories in women considering elective CS from third-trimester pregnancy to 6 months post-CS and 2) to examine associations of sleep trajectories with body mass index (BMI), depressive symptoms, and fatigue scores. METHODS We analyzed data from a prospective cohort study of 139 Taiwanese pregnant women who elected CS. Sleep components were assessed using the Pittsburgh Sleep Quality Index in third-trimester pregnancy, 1 day, 1 week, 1 month, and 6 months post-CS. Data were collected on depressive symptoms, fatigue symptoms, and BMI. Sleep-quality trajectories were identified by group-based trajectory modeling. RESULTS We identified three distinct trajectories: stable poor sleep (50 women, 36.0%), progressively worse sleep (67 women, 48.2%), and persistently poor sleep (22 women, 15.8%). Poor sleep was significantly associated with pre-pregnancy BMI and more baseline (third-trimester pregnancy) depressive and fatigue symptoms. At 6 months post-CS, women classified as progressively worse or persistently poor sleepers showed a trend toward higher BMI (p<0.03), more depressive symptoms (p<0.001), and higher fatigue scores (p<0.001) than those with stable poor sleep. CONCLUSIONS Women had three distinct sleep-disturbance trajectories before and after elective CS. These poor-sleep courses were associated with BMI and psychological well-being. Our findings suggest a need to continuously assess sleep quality among women considering elective CS and up to 6 months post-CS.
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Affiliation(s)
- Ya-Ling Tzeng
- School of Nursing, China Medical University and China Medical University Hospital, Taichung, Taiwan
| | - Shu-Ling Chen
- Department of Nursing, Hungkuang University, Taichung, Taiwan
| | - Chuen-Fei Chen
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Fong-Chen Wang
- School of Nursing, China Medical University and China Medical University Hospital, Taichung, Taiwan
| | - Shu-Yu Kuo
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
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26
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Kotan Z, Bican A, Kotan VO, Bora İ, Yalvac HD, Ozkaya G, Akkaya C. Sleep measurements in women with dysthymic disorder and insomnia. Sleep Biol Rhythms 2014. [DOI: 10.1111/sbr.12092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Zeynep Kotan
- Department of Psychiatry; Abdurrahman Yurtaslan Ankara Onkoloji Training and Research Hospital; Ankara Turkey
| | - Aylin Bican
- Department of Neurology Medicine; Uludag University, Medical Faculty; Bursa Turkey
| | - Vahap Ozan Kotan
- Department of Psychiatry; Ankara Numune Training and Research Hospital; Ankara Turkey
| | - İbrahim Bora
- Department of Neurology Medicine; Uludag University, Medical Faculty; Bursa Turkey
| | - Hayriye Dilek Yalvac
- Department of Psychiatry; Abdurrahman Yurtaslan Ankara Onkoloji Training and Research Hospital; Ankara Turkey
| | - Güven Ozkaya
- Department of Biostatistics; Uludag University, Medical Faculty; Bursa Turkey
| | - Cengiz Akkaya
- Department of Psychiatry; Uludag University, Medical Faculty; Bursa Turkey
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