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

Association between sleep duration and quality with food intake, chrononutrition patterns, and weight gain during pregnancy

To analyse the association between sleep duration and quality with food intake, chrononutrition patterns, and weight gain during pregnancy. A prospective cohort study was conducted with 100 pregnant women. Data collection occurred once during each gestational trimester. The assessment of sleep quality and duration was performed using the Pittsburgh Sleep Quality Index. Food intake was assessed using three 24-h recalls in each trimester. Body weight was measured during the three trimesters, and height was measured only once to calculate the BMI. Linear regression analyses were performed to associate sleep duration and quality with food consumption and weight gain variables. Longer sleep duration was associated with a later dinner in the first trimester (β = 0·228, P = 0·025) and earlier in the third trimester (β = -0·223, P = 0·026), in addition to a later morning snack in the second trimester (β = 0·315, P = 0·026). Worse sleep quality was associated with higher total energy intake (β = 0·243, P = 0·044), total fat (β = 0·291, P = 0·015) and the chrononutrition variables such as a higher number of meals (β = 0·252, P = 0·037), higher energetic midpoint (β = 0·243, P = 0·044) and shorter fasting time (β = -0·255, P = 0·034) in the third trimester. Sleep quality was also associated with a higher BMI in the first trimester of pregnancy (β = 0·420, P = < 0·001). Most of the associations found in the present study show that poor sleep is associated with higher energy and fat intake and higher BMI. Longer sleep duration was associated with a later dinner in early pregnancy and an earlier dinner in late pregnancy, as well as with a later morning snack in the second trimester of pregnancy.

Patterns of prescription opioid use and opioid-related harms among adult patients with hematologic malignancies

INTRODUCTION

Treatment advances for hematologic malignancies (HM) have dramatically improved life expectancy, necessitating greater focus on long-term cancer pain management. This study explored real-world patterns of opioid use among patients with HM.

METHODS

This retrospective cohort study identified adults diagnosed with HM from January 1, 2013 through December 31, 2019 using the Truven MarketScan Commercial Claims and Encounters database. Across several HM types, we described rates of high-risk opioid use (based on Pharmacy Quality Alliance measures) and opioid-related harms, including incident opioid use disorder (OUD) diagnoses and opioid-related hospitalizations or emergency department (ED) visits. We used multivariable Cox regression to generate adjusted hazard ratios and 95% confidence intervals comparing the risk of opioid-related harms between patients with versus without high-risk opioid use.

RESULTS

Our sample included 43,190 patients with HM. Median age at HM diagnosis was 54 years (interquartile range  =  44-60). Most patients (61.9%) were diagnosed with lymphoma. Approximately half (49.2%) had an opioid dispensed in the follow-up period. Among all patients, 20.0% met criteria for high-risk opioid use, 0.9% had an OUD diagnosis, and 0.3% experienced an opioid-related hospitalization/ED visit in follow-up. High-risk opioid use increased the risk of an OUD diagnosis by 3.3 times (p < 0.0001) and an opioid-related hospitalization/ED visit 4.2 times (p < 0.0001).

CONCLUSION

High-risk opioid use was prevalent among patients with HM and significantly increased the risk of opioid-related harms. However, rates of opioid-related harms were low. These findings highlight the importance of continually monitoring pain and opioid use throughout HM survivorship to provide safe, effective HM pain management.

The association between multidimensional sleep health and gestational weight gain

BACKGROUND

Although poor sleep health is associated with weight gain and obesity in the non-pregnant population, research on the impact of sleep health on weight change among pregnant people using a multidimensional sleep health framework is needed.

OBJECTIVES

This secondary data analysis of the Nulliparous Pregnancy Outcome Study: Monitoring Mothers-to-be Sleep Duration and Continuity Study (n = 745) examined associations between mid-pregnancy sleep health indicators, multidimensional sleep health and gestational weight gain (GWG).

METHODS

Sleep domains (i.e. regularity, nap duration, timing, efficiency and duration) were assessed via actigraphy between 16 and 21 weeks of gestation. We defined 'healthy' sleep in each domain with empirical thresholds. Multidimensional sleep health was based on sleep profiles derived from latent class analysis and composite score defined as the sum of healthy sleep domains. Total GWG, the difference between self-reported pre-pregnancy weight and the last measured weight before delivery, was converted to z-scores using gestational age- and BMI-specific charts. GWG was defined as low (<-1 SD), moderate (-1 or +1 SD) and high (>+1 SD).

RESULTS

Nearly 50% of the participants had a healthy sleep profile (i.e. healthy sleep in most domains), whereas others had a sleep profile defined as having varying degrees of unhealthy sleep in each domain. The individual sleep domains were associated with a 20%-30% lower risk of low or high GWG. Each additional healthy sleep indicator was associated with a 10% lower risk of low (vs. moderate), but not high, GWG. Participants with late timing, long duration and low efficiency (vs. healthy) profiles had the strongest risk of low GWG (relative risk 1.5, 95% confidence interval 0.9, 2.4). Probabilistic bias analysis suggested that most associations between individual sleep health indicators, sleep health profiles and GWG were biased towards the null.

CONCLUSIONS

Future research should determine whether sleep health is an intervention target for healthy GWG.

Perceptions of prescription opioids among marginalized patients with hematologic malignancies in the context of the opioid epidemic: a qualitative study

PURPOSE

Opioids are essential for treating pain in hematologic malignancies (HM), yet are heavily stigmatized in the era of the opioid epidemic. Stigma and negative attitudes towards opioids may contribute to poorly managed cancer pain. We aimed to understand patient attitudes towards opioids for HM pain management, particularly among historically marginalized populations.

METHODS

We interviewed a convenience sample of 20 adult patients with HM during outpatient visits at an urban academic medical center. Semi-structured interviews were audio-recorded, transcribed, and qualitatively analyzed using the framework method.

RESULTS

Among 20 participants, 12 were female and half were Black. Median age was 62 (interquartile range = 54-68). HM diagnoses included multiple myeloma (n = 10), leukemia (n = 5), lymphoma (n = 4), and myelofibrosis (n = 1). Eight themes emerged from interviews that seemed to influence HM-related pain self-management, including (1) fear of opioid-related harms, (2) opioid side effects and harms to health, (3) fatalism and stoicism, (4) perceived value of opioids for HM-related pain, (5) low perceived susceptibility to opioid-related harms and externalizing blame, (6) preferences for non-opioid pain management approaches, (7) trust in providers and opioid accessibility, and (8) external sources of pain management support and information.

CONCLUSIONS

This qualitative study demonstrates that fears and stigmatized views of opioids can conflict with marginalized patients' needs to manage debilitating HM-related pain. Negative attitudes towards opioids were shaped by the opioid epidemic and reduced willingness to seek out or use analgesics.

IMPLICATIONS FOR CANCER SURVIVORS

These findings help expose patient-level barriers to optimal HM pain management, revealing attitudes, and knowledge to be targeted by future pain management interventions in HM.

Sleep During Pregnancy

PURPOSE OF REVIEW

This article will provide a brief review of most recent findings of sleep, insomnia, obstructive sleep apnea, and restless leg syndrome during pregnancy.

RECENT FINDINGS

Recent meta-analyses have found that 38.2% of pregnant women experience insomnia, 15% experience obstructive sleep apnea, and 20% experience restless leg syndrome. Poor sleep during pregnancy is associated with increased odds of preterm birth, cesarean section, hypertension, gestational diabetes, and longer deliveries. OSA is also associated with poor outcomes such as maternal hypertension, gestational diabetes, preterm birth, and low infant Apgar score. Incidence of new-onset RLS increases with parity, gestational age, maternal age, and increased maternal adiposity. Typical treatments have been found to be effective for treating sleep disorders in pregnant women. Obtaining sufficient sleep quality and quantity in addition to assessing and treating sleep disorders should be a priority for pregnant women and their providers.

Sleep Disturbance in Pregnancy

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

Sleep Disorders During Pregnancy and Postpartum: A Systematic Review

This study aimed to asses previous research results about bio-physiological alterations during pregnancy and postpartum, and make clear outlook about prevalence and related factors of sleep disorders during pregnancy and postpartum. In this review, the articles that published from 2000 to 2019 were reviewed. Related articles were searched from databases in English language. After evaluation of inclusion and exclusion criteria, articles were chosen and reviewed based on the University of York strategies. Sleep disorders in present study were classified according to the International Classification of Sleep Disorders-3. The search revealed 4449 articles, after evaluating and assessing qualified articles, finally 56 article selected to review. According to the results of this review, The prevalence of sleep disorders was almost 76%–97% in whole pregnancy. The most common sleep disorders included central disorders of hyper somnolence (waking up in the middle of the night, daytime sleepiness, sleeplessness) or insomnia, sleep-related movement disorders (restless legs syndrome), sleep related breathing disorders (obstructive sleep apnea), and parasomnia. In addition, sleep disorder may continue 3–12 months postpartum (33.2%). Sleep disorders induced by physiological processes (fetal movement, excessive weight gain, male sex of the fetus, and multiparty), health-related risks (metabolism disorders, cardiovascular diseases, and mood disorders), and physical or sexual abuse in childhood. In addition, these disorders could have maternal outcomes that can be greatest trigger to postpartum psychiatric disorders and fetal outcomes that have harmful sequences during childhood (sexual, fertility, emotional, and cognitive problems). Health care providers should evaluate the mothers’ sleep quality because sleep disorder leads to harmful consequences in fetuses and children.

Objective sleep efficiency but not subjective sleep quality is associated with longitudinal risk of depression in pregnant women: A prospective observational cohort study

BACKGROUND

Sleep disturbances are one of the most frequent chief complaints brought to the healthcare professionals during routine prenatal care visits. Sleep and mood disturbances are often intertwined, and depression in particular is a leading cause of disability and disease burden worldwide with women more likely to be affected than men. However, limited studies have prospectively investigated the association between sleep disturbances and longitudinal risk of depression in pregnant women, with no studies using actigraphy to objectively estimate daytime and nighttime sleep duration and the extent of sleep disruption.

OBJECTIVES

To examine the predictive and longitudinal association of objective actigraphic and subjective sleep disturbances with depressive symptoms in pregnant women.

DESIGN

A prospective observational cohort study.

METHODS

204 1st trimester pregnant women recruited from a university-affiliated hospital provided socio-demographic and health information, wore a wrist actigraph for 7 days, and completed Pittsburgh Sleep Quality Index, Center for Epidemiologic Studies - Depression Scale, and Epworth Sleepiness Scale. Identical data collection procedures were implemented again in the 2nd and 3rd trimester, with each data collection scheduled at least 8 weeks apart. We estimated unadjusted and multivariable adjusted odds ratios and 95% confidence intervals to evaluate various types of sleep disturbances at 1st trimester and risk of depression at follow-ups.

RESULTS

121 (59.3%) 1st trimester women had a sleep efficiency of < 85% by actigraphy, and 92 (45.1%) had Pittsburgh Sleep Quality Index global scores > 5 indicative of poor sleep quality. In multivariable adjusted models, 1st trimester objectively measured sleep efficiency < 85% was associated with 2.71-, 3.87-, and 5.27-fold increased odds having risk of depression at 2nd trimester, 3rd trimester, and both 2nd and 3rd trimesters, respectively.

CONCLUSIONS

Healthy pregnant women experience both objective and subjective sleep disturbances during the early trimester, with a substantial proportion of them also having high depressive symptoms throughout the pregnancy. Objectively assessed poor sleep quality in the 1st trimester, but not self-reported characteristics of disturbed sleep, may play a role in the development of both elevated and persistent high depressive symptoms in pregnancy. Future studies using objective sleep measurements and clinical diagnostic interviews are warranted to examine whether an early intervention aiming at improving sleep may help reduce high depressive symptom risk and lower depression rate in women during pregnancy. Tweetable abstract: Objectively assessed poor sleep efficiency in the 1st trimester predicts both elevated and persistent high depressive symptoms in pregnancy.

Associations of Sleep With Sedentary Behavior and Physical Activity Patterns Across Pregnancy Trimesters

INTRODUCTION

Sleep, sedentary behavior, and moderate-to-vigorous physical activity (MVPA) are altered in pregnancy and may affect pregnancy health; however, how these behaviors are associated with each other is unclear.

METHODS

Pregnant women (N = 120) completed the Pittsburgh Sleep Quality Index and wore an activPAL3 micro and ActiGraph GT3X for 7 days in each trimester to assess sleep, sedentary behavior, and MVPA, respectively. Latent trajectories described patterns of sleep duration, efficiency, and quality as well as sedentary behavior and MVPA. Multinomial logistic regression examined associations of sleep patterns with sedentary behavior and MVPA patterns and, in exploratory analyses, with adverse pregnancy outcomes.

RESULTS

Trajectories were identified for sleep duration (consistently short, 20.7% of sample; consistently adequate, 79.3%), efficiency (consistently low, 17.5%; consistently high, 82.5%), and quality (consistently poor, 15.1%; worsening, 23.5%; and consistently good, 61.5%). Compared with those in more optimal sleep groups, women in the short duration, low efficiency, and worsening quality groups had lower odds of being in the moderate and/or high sedentary behavior group (odds ratio range, 0.21-0.31; 95% confidence interval range, 0.09-0.65). Women in the worsening quality group had greater odds of being in the low MVPA group (odds ratio, 2.51; 95% confidence interval, 1.18-5.38). Trends were observed with women in less optimal sleep groups having greater odds of adverse pregnancy outcomes and lower odds of excessive gestational weight gain.

CONCLUSIONS

Less optimal sleep patterns in pregnancy are associated with less sedentary behavior and MVPA; additional research is needed to confirm associations between sleep and pregnancy outcomes.

Associations of History of Displacement, Food Insecurity, and Stress With Maternal-Fetal Health in a Conflict Zone: A Case Study

Background: In populations with a history of conflict, early identification of pregnant women who are at risk of adverse pregnancy outcomes is challenging, especially if sonography is not available. We evaluated the performance of symphysis-fundal height (SFH) for identification of high-risk pregnancies and investigated if food security and diet quality, clinical biomarkers, and stress were associated with SFH and two known indicators of maternal-fetal well-being, sonography-estimated fetal weight and amniotic fluid index (AFI).

Methods: For this cross-sectional study, 61 women with high-risk pregnancies were recruited after referral to the obstetrics and gynecology unit at San José Hospital in Popayán, Colombia. Multiple stepwise linear and ordered logistic regressions were used to identify associations of SFH, sonography-estimated fetal weight and AFI classification with history of displacement, food insecurity, post-traumatic stress symptoms as well as biopsychosocial risk evaluated through the Colombian risk scale.

Results: History of displacement was associated with lower SFH Z-scores, but higher hemoglobin, taking iron supplements and a higher diastolic blood pressure were associated with higher SFH Z-scores. SFH was also associated with AFI but not with sonography-estimated fetal weight. Stress indicators were associated with a higher AFI. In contrast family support, an element of the Colombian biopsychosocial risk assessment, was associated with a higher sonography-estimated fetal weight, whereas more hours of sleep/day were associated with lower sonography-estimated fetal weight.

Conclusion: SFH was not only associated with biological factors known to affect maternal/fetal health but also with history of displacement, thus validating its use in conflict areas for pregnancy assessment. Associations of biopsychosocial stressors with maternal-fetal outcomes highlight the need for a systematic assessment of stress in pregnant women from conflict zones.

Symptoms of Daytime Sleepiness and Sleep Apnea among Pregnant Women

Objectives

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

Methods

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

Results

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

Conclusions

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

Characteristics of sleep/wake problems and delivery outcomes among pregnant Japanese women without gestational complications

Background

Frequently observed sleep/wake problems among pregnant women need comprehensive evaluation. This study was conducted to clarify the sleep/wake problems among pregnant women without gestational complications during the second and third trimester and the effects of sleep/wake problems on delivery outcomes.

Methods

A total of 88 Japanese pregnant women participated in this study. In their second and third trimester, subjective sleep quality, insomnia severity, excessive daytime sleepiness (EDS), and restless legs syndrome/Willis-Ekbom disease (RLS/WED) were assessed using questionnaires; also, sleep disordered breathing (SDB) was screened using a pulse oximeter.

Results

From the second to the third trimester, an increasing tendency of sleep/wake problems was observed. During the third trimester, the percentages of women experiencing decreased subjective sleep quality, difficulty maintaining sleep (DMS), EDS, RLS/WED, and 3% oxygen desaturation index (ODI) values ≥5/h were 62.5, 45.5, 48.9, 9.1, and 29.5%, respectively. In a logistic regression analysis for EDS in the third trimester, the adjusted odds ratio (95% confidence interval) of total sleep duration < 6 h, moderate to severe DMS, and 3% ODI values ≥5/h were 3.25 (1.16–9.10), 4.74 (1.60–14.00), and 0.90 (0.28–2.89), respectively. Although short sleep durations, decreased subjective sleep quality, EDS, and SDB did not affect delivery outcomes or the infant’s condition, the percentage of women undergoing cesarean sections in the severe insomnia group was significantly higher (p = 0.008).

Conclusions

Sleep/wake problems were frequent during pregnancy, especially during the third trimester. EDS among pregnant women was associated with shorter sleep durations and DMS rather than SDB. The effect of factors related to insomnia on delivery outcomes should thus be considered a crucial problem among pregnant Japanese women without gestational complications in clinical practice.