Restless legs syndrome and pregnancy: a review

Effect of dairy products fortified with vitamin d3 on restless legs syndrome in women with premenstrual syndrome, abdominal obesity and vitamin d deficiency: a pilot study

BACKGROUNDS

Restless legs syndrome (RLS) is an unpleasant condition that affects the quality of life of patients. Its prevalence in increased in women with premenstrual syndrome (PMS). Vitamin D plays a key role in female reproduction through its impact on calcium homeostasis and neurotransmitters. We aimed to evaluate the effect of dairy products fortified with Vitamin D3 on RLS in women with PMS.

MATERIALS AND METHODS

We conducted a 2.5-month, randomized, total-blinded clinical trial to evaluate the effectiveness of low-fat milk and yogurt fortified with vitamin D on RLS in women with PMS. Among 141 middle-aged women with abdominal obesity, 71 and 70 cases received fortified and non-fortified low-fat dairy products, respectively. All subjects completed a Symptoms Screening Tool (PSST) and RLS questionnaires.

RESULTS

The results showed that in the women with severe PMS (PSST > 28), serum levels of vitamin D increased significantly following vitamin D fortification. The mean restless legs score in the severe PMS subgroup (PSST > 28) was significantly lower after the intervention (p < 0.05. Serum Vitamin D levels significantly differed between intervention and control groups in all individuals (PSST < 19, PSST 19-28, and PSST > 28) (p < 0.05), but no significant differences were found between RLS scores of the intervention and control groups in the three PMS subgroups (p > 0.05).

CONCLUSION

Fortifying dairy products with vitamin D3 can increase the serum levels of vitamin D and reduce the RLS severity in women with severe PMS, but not in other groups.

Diagnosis and management of common sleep disorders during the perinatal period

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.

Evaluation of the relationship between restless legs syndrome, mental status, and sleep disorders among Moroccan women during their third trimester of pregnancy

Background

Restless legs syndrome (RLS) is a motor disorder encountered during pregnancy and leads to psychological and sleep impairments. The latter seems to be non-restorative and its occurrence alters the quality of life of pregnant women. The objective of this study was to evaluate the prevalence of RLS and its relationship with both anxio-depressive symptoms and sleep disorders among a population of Moroccan pregnant women during their third trimester of pregnancy.

Methods

A cross-sectional study was conducted in a population of pregnant women in their third trimester (n=178) admitted to two health facilities in the city of Marrakech: Youssef Ibn Tachafine and Oasis. The face-to-face questionnaire was used to collect data including demographic and clinical characteristics, the four diagnostic criteria of RLS, the Pittsburgh Sleep Quality Index (PSQI), and the Hospital Anxiety and Depression Scale (HADS). Patients were divided into two groups RLS+ (women with RLS) and RLS- (women without RLS).

Results

The prevalence of RLS was 59.5%; this syndrome was more common in the ninth month (74.15%) compared with the seventh and eighth months. Sleep impairment, including sleep efficiency, was significantly higher in RLS+ than RLS- (P-value 0.05). Anxiety but not depression is significantly increased in RLS+ compared to RLS- (48.11% versus 38.8%, P = 0.000). There were no significant differences between RLS+ and RLS- in terms of socio-demographic and other clinical characteristics.

Conclusion

RLS is encountered during the prenatal period, with a higher prevalence in the last trimester. During this stage of pregnancy, women suffering from RLS were vulnerable to anxiety and sleep disorders. Prevention and early diagnosis of RLS could be a proactive healthcare management leading to better health outcomes and better conditions of pregnancy, which precedes childbirth.

Sleep pattern and disorders among pregnant women in Ibadan, Southwest Nigeria

BACKGROUND

Sleep is essential for pregnant women's and the offspring's health and wellbeing. Poor sleep and disorders have been linked with adverse fetal outcomes and delivery conditions. However, pregnant women often experience several forms of sleep disruption, which has been scarcely reported in low and middle-income countries (LMIC), including Nigeria where the influence of lifestyle factors has also been lacking. We investigated sleep patterns and disorders and the associated factors among pregnant women in Southwest, Nigeria.

METHOD

A cross-sectional study was conducted among five hundred (500) pregnant women attending Adeoyo Maternity Teaching Hospital. A semi-structured questionnaire was used to examine different domains of sleep and associated disorders, namely sleep quality (Pittsburgh Sleep Quality Index (> 5 and ≤ 5)), insomnia (Insomnia Severity Index (> 8 and ≤ 8)), restless leg syndrome (Restless Leg Syndrome Rating Scale (> 10 and ≤ 10). Significant covariates such as physical activity, minimum dietary diversity, smoking and alcohol intake were also assessed. We conducted bivariate and multivariate analysis at p < 0.05 significance level.

RESULTS

The mean age of participants was 30.4 ± 4.8 years. The pattern of sleep disorder in pregnant were poor sleep quality (50%), restless leg syndrome (58.2%) and insomnia (33.4%). Being currently married (AOR = 6.13; 95% CI: (1.65-22.23)), increasing gestational age: second trimester (AOR = 8.25;95% CI: (1.78-38.17)) to third trimester (AOR = 10.98; 95% CI: (2.44-49.48)) increased the odds of poor sleep quality. Factors associated with restless leg syndrome were marital status [AOR = 3.60; 95% CI; (1.25-10.35)], religion, rigorous physical activities [AOR = 1.52; 95% CI: (1.05-2.21)] and alcohol consumption [AOR = 3.51; 95% CI: (1.00-12.27)]. Factors associated with insomnia were maternal age [AOR = 1.83; 95% CI: (1.11-3.01)], income [AOR = 2.99 (1.26-7.16)] and rigorous physical activity [AOR = 2.55 (1.61-4.02)].

CONCLUSION

Poor sleep quality, restless leg syndrome and insomnia were typical among pregnant women in Ibadan, Southwest Nigeria. Thus, awareness and education on the importance of sleep and its risk and protective factors, such as alcohol consumption, smoking, rigorous activity and spousal and family support, should be increased to reduce poor sleep quality and sleep disorders (restless leg syndrome and insomnia) during the pregnancy period.

A comprehensive update on the ADMET considerations for α2δ calcium channel ligand medications for treating restless legs syndrome

INTRODUCTION

Restless legs syndrome/Willis-Ekbom disease (RLS/WED) is a sleep-related sensory-motor disorder associated with poor sleep quality and impaired daily functioning. In patients affected by chronic RLS/WED, a pharmacological therapy is recommended. International guidelines suggest to start the treatment with a α2δ calcium channel ligand in most cases, unless contraindicated.

AREAS COVERED

The present review is based on an extensive Internet and PubMed search from 1986 to 2024. Our purpose is to describe the absorption, distribution, metabolism, and toxicology (ADMET) of the α2δ ligands, with common consideration for the therapeutic class, specificities of different compounds, efficacy, and safety in relation to other treatment options.

EXPERT OPINION

α2δ ligands are quite similar in their ADMET profiles, sharing most of the pharmacokinetics and potential adverse effects. However, we highlight the linear kinetic of gabapentin enacarbil and pregabalin, differently from gabapentin. α2δ ligands are safe and effective for the treatment of RLS/WED. Additional benefits can be obtained in comorbid insomnia, chronic pain syndromes, history of impulse control disorder, and comorbid anxiety. The use of α2δ ligands is associated with poor risk of augmentation. We still need new long-term safe and effective treatments, which could be developed along with our knowledge of RLS/WED pathophysiology.

New-onset movement disorder in the immediate postpartum period

This case report describes a woman who developed involuntary, uncoordinated movements of her face and limbs following a spontaneous vaginal delivery, complicated by postpartum haemorrhage. Using systematic assessment with multidisciplinary team input, a differential diagnosis was proposed and relevant investigations were undertaken. Atypical eclamptic or generalised seizures were excluded clinically and neuroimaging ruled out an intracranial vascular event such as stroke or venous sinus thrombosis. Local anaesthetic systemic toxicity was managed empirically with intravenous lipid emulsion and intravenous fluids. A diagnosis of drug-induced dyskinesia was made, most likely secondary to ondansetron, with which dystonias and myoclonus have been described. This woman's symptoms were transient and resolved within 2 hours.This case presented a complex differential diagnosis, highlighting the paucity of guidance available. We propose a diagnostic algorithm to aid in the identification of acute involuntary movements in pregnancy and the puerperium.

Prevalence and factors associated with restless legs syndrome among pregnant women in middle-income countries: a systematic review and meta-analysis

Introduction

Restless legs syndrome (RLS) is a debilitating condition characterized by uncomfortable sensations in the legs, typically occurring during periods of rest or sleep. It is more prevalent during pregnancy and is linked to sleep disturbances, diminished quality of life, and pregnancy complications. However, previous studies yielded inconsistent findings among pregnant women in middle-income countries. Consequently, this systematic review and meta-analysis sought to determine the pooled prevalence of restless legs syndrome and its associated factors in these populations.

Method

A systematic review and meta-analysis was conducted on published studies from middle-income countries until May 2023. The review strictly adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant search terms were used to search for studies in PubMed, MEDLINE, EMBASE, and Google Scholar. Data extraction was performed using the Joanna Briggs Institute tool for prevalence studies. The meta-analysis was conducted using STATA 17 software, and heterogeneity was assessed using the I2 test, while publication bias was evaluated using Egger's test. Forest plots were also used to present the pooled prevalence and odds ratio (OR) with a 95% confidence interval (CI) using the random-effects model.

Result

This review included 22 studies from nine countries with a total of 17, 580 study participants. The overall pooled prevalence of RLS among pregnant women in middle-income countries was 13.82% (95% CI: 13.31, 14.32), and having low hemoglobin level (AOR: 1.68, 95% CI: 1.29, 2.18), history of RLS (AOR: 7.54, 95% CI: 3.02, 18.79), muscle cramps (AOR: 3.58, 95% CI: 1.21, 10.61), excessive day time sleepiness (AOR: 4.02, 95% CI: 1.34, 12.04), preeclampsia (AOR: 2.06, 95% CI: 1.28, 3.30), and taking prophylactic iron supplementation (AOR: 0.59, 95% CI: 0.50, 0.69) were the identified factors associated with it.

Conclusion

Generally, nearly one in every eight pregnant women in middle-income countries develop restless legs syndrome during pregnancy. Having low hemoglobin level, a history of RLS, muscle cramps, excessive daytime sleepiness, preeclampsia, and taking prophylactic iron supplementation were the identified factors associated with it. These findings underscore the importance of addressing the identified factors associated with RLS in order to effectively mitigate its occurrence among pregnant women.

The Prevalence, Severity, and Predictive Factors of Restless Legs Syndrome in Pregnancy

OBJECTIVES

 The current study aimed to search the prevalence and severity of restless legs syndrome (RLS) in pregnancy according to the three trimesters and predictive factors of RLS in pregnancy based on validated diagnostic tools and a thorough literature review.

METHODS

The cross-sectional descriptive study included 500 pregnant women without comorbidities who were interviewed face-to-face. Age, height, weight, week of pregnancy, smoking, alcohol, caffeine use, regular exercise, and lab test results from the last visit were all included in the data. Only women satisfying the RLS diagnostic criteria were given the Restless Legs Syndrome Rating Scale.

RESULTS

The prevalence of RLS was found to be 29.2% with the highest rate in the third trimester (64.4%). In all trimesters, low ferritin (first trimester: p = 0.004; second trimester: p < 0.001; third trimester: p < 0.001), folic acid (first trimester: p = 0.001; second trimester: p < 0.001; third trimester: p < 0.001), vitamin B12 (first trimester: p = 0.003; second trimester: p < 0.001; third trimester: p < 0.001), and hemoglobin (first trimester: p < 0.001; second trimester: p < 0.001; third trimester: p < 0.001) levels were associated with RLS. In the second and third trimesters, low magnesium (p < 0.001 and p < 0.001, respectively) and high creatinine (p = 0.027 and p < 0.001, respectively) levels were associated with RLS. Higher thyroid-stimulating hormone and free T4 levels were associated with RLS in the third trimester but not in the first and second trimesters (median: 2.4 vs. 2.1, p < 0.001; median: 1.5 vs. 1.2, p < 0.001). In the multivariate regression analysis, age (p = 0.034, OR: 1.060, 95% CI: 1.005-1.119), present BMI (p < 0.001, OR: 1.8884, 95% CI: 1.597-2.222), BMI before conception (p < 0.001, OR: 0.607, 95% CI: 0.513-0.718), gravida (p < 0.001, OR: 2.172, 95% CI: 1.547-3.049), low ferritin level (p < 0.001, OR: 6.396, 95% CI: 0.00744-0.010405), low vitamin B12 (p < 0.001, OR: 10.347, 95% CI: 0.00120-0.00176), low folate (p < 0.001, OR: 5.841, 95% CI: 0.00616-0.01240), RLS history before conception (p = 0.013, OR: 4.963, 95% CI: 1.402-17.57), and RLS family history (p < 0.001, OR: 7.914, 95% CI: 0.18760-0.31151) were found to be predictive factors for RLS in pregnancy.

CONCLUSION

More attention is needed to RLS during pregnancy to prevent or treat this syndrome.

Possible etiologies of restless legs syndrome in pregnancy: a narrative review

Restless legs syndrome (RLS) is a sensorimotor disorder characterized by an urgent need to move the legs, due to the presence of a discomfort sensation in the lower limbs, especially at rest. Generally, it relieves with movement. There are several studies that argue the existence of an association between this syndrome and pregnancy. However, the pathophysiological mechanisms of this disorder in pregnancy are misunderstood. The objective of this narrative review is to identify and discuss some possible etiologies of RLS in pregnancy. A literature search was performed in the PubMed and ResearchGate databases by using the following search strategies: "restless legs syndrome", "restless legs syndrome in pregnancy", "pregnancy and vitamin D deficiency" and "pregnancy and zinc". The publications were initially sorted through their title. After the initial process, inclusion and exclusion criteria were applied. The included articles were sorted by authors, year, journal of publication, type of study, and organized by chronological order of publication. Among the main findings, hormonal changes, iron metabolism, vitamin D deficiency, genetic factors, zinc and magnesium fluctuations have been some of the hypotheses supporting the development or worsening of this disorder in pregnancy. Dopamine also appears to be correlated with hormonal changes, iron metabolism, ferritin, folic acid and vitamin D deficiency. In conclusion, there are several hypotheses trying to link restless legs syndrome with pregnancy. The most covered were hormonal fluctuations and iron metabolism. However, this thematic is still highly discussed, creating the need for additional and thorough research.

The effect of vitamin D on sleep quality: A systematic review and meta-analysis

Background: Poor sleep quality is a common problem in the general population that affects the quality of life of individuals. Aim: This systematic review aimed to determine the effect of vitamin D on sleep quality (primary outcome) and side effects (secondary outcome). Methods: A systematic search was performed using Cochrane Library, PubMed, Embase, Web of Sciences, Scopus, Google Scholar, SID, and Magiran databases with no limit at the time of publication. Cochrane collaboration instrument was used to evaluate the quality of the included studies. RevMan software was used for meta-analysis. Mean Difference was calculated due to the same sleep quality measurement tools in all studies. Heterogeneity of studies was assessed using I-squared (I2). Due to high heterogeneity (I2 > 75%), Random Effect was used instead of Fixed Effect. Results: Out of a total of 1637 titles and abstracts found, after removing duplicate items (23 items), 1596 items were removed due to irrelevance and lack of inclusion criteria. 18 articles were fully studied due to insufficient abstract information and finally, 5 articles were entered into systematic review and meta-analysis. The results of the meta-analysis showed that the use of vitamin D supplementation significantly improves sleep quality (MD: -1.32; 95%CI: -2.55 to -0.09; P = 0.04). Conclusions: Also, according to the findings of this study, receiving vitamin D supplementation did not cause any side effects. According to the results of this review study, sleep quality in people receiving vitamin D significantly improved compared to the control group.

Prevalence and associated factors of restless leg syndrome (RLS) in Pakistani women during pregnancy

There is a dearth of literature studying restless leg syndrome (RLS) among pregnant patients in Pakistan. The objective of this study was to determine the prevalence and associated factors of RLS among pregnant Pakistani patients. It was conducted in 2018 among 478 women attending ante-natal check-up in the outpatient department of five hospitals in Karachi, Pakistan. Individuals were interviewed for socio-demographic information, the key criteria for RLS and its associated factors. RLS was reported in 54 (11%) individuals based on International Restless Legs Syndrome Study Group (IRLSSG) criteria. The mean age was 33.44 ± 4.42 years. Association between pregnant women with RLS and those without reveals statistically significant differences with increasing age (p=.01), gravida (p<.01) and para (p<.001). RLS was significant among working women (p=.001), during third trimester (p=.001), with insomnia (p<.001), use of tobacco (p<.001) and among women with gestational diabetes (p<.001), hypertension (p<.001). The study showed a low prevalence of RLS among women during pregnancy. It further reported gestational diabetes, hypertension, insomnia and tobacco use to be independently linked to RLS. Impact StatementWhat is already known on this subject? Pregnancy has been demonstrated to be strongly associated with development of secondary restless leg syndrome (RLS). RLS in pregnancy has also been shown to portend poor maternal and neonatal outcomes such as postpartum depression and preterm birth. Various conditions and lifestyle factors in pregnancy have been shown to be associated with the development of RLS, but there are variations in these across different populations.What do the results of this study add? The prevalence of RLS was only reported twice in pregnant patients in Pakistan and our research helps to address this data shortage. In addition, the results of our study document a strong association of RLS with gestational hypertension and gestational diabetes and also show that smoking and exercise were correlated with RLS during pregnancy, both of which were previously unstudied in the pregnant Pakistani population.What are the implications of these findings for clinical practice and/or further research? Demonstrating the prevalence of RLS in pregnant Pakistani patients highlights the need to screen these patients, particularly those with associated conditions identified in our findings, for RLS during antenatal visits and to treat their condition to improve maternal and neonatal outcomes.

Relationship of restless legs syndrome with number of pregnancies, duration of pregnancy and positive family history

Objectives:

The aim of this cross-sectional study was to examine the correlation between gestational age and number of previous pregnancies in group of pregnant women with restless legs syndrome and the connection of restless legs syndrome with family history positive versus family history negative group of pregnant and non-pregnant women.

Methods:

Four hundred and sixty-two women were involved in this study: 231 pregnant women and the same number of non-pregnant women of compatible age as a control group. We defined restless legs syndrome as presence of International Restless Legs Syndrome Study Group criteria. During the face-to-face interview with the researcher, respondents answered questions about duration of pregnancy, number of previous pregnancies and family history of restless legs syndrome.

Results:

Before the 16th week of pregnancy, restless legs syndrome appeared in 7.1% of pregnant women and after 16 weeks of pregnancy in 22.6% of them (t = 2.07, p = 0.039). Restless legs syndrome appeared in 11.4% of pregnant women without restless legs syndrome in the family and in 74.2% of pregnant women who did have restless legs syndrome in the family (t = 7.67, p < 0.001). It was also found that among non-pregnant women with a family history of restless legs syndrome, 42.9% had restless legs syndrome, and among those without a family history of restless legs syndrome, only 4.9% had restless legs syndrome (t = 3.49, p = 0.001). No statistically significant correlation between restless legs syndrome and number of previous pregnancies in pregnant women has been found.

Conclusion:

Our study confirmed a higher frequency of restless legs syndrome in women pregnant for 17 or more weeks and in both pregnant and non-pregnant women with a positive family history of this syndrome. We have not proven a connection between restless legs syndrome and multiparity.

Phenotypical predictors of pregnancy-related restless legs syndrome and their association with basal ganglia and the limbic circuits

Restless legs syndrome (RLS) in pregnancy is a common disorder with a multifactorial etiology. A neurological and obstetrical cohort of 308 postpartum women was screened for RLS within 1 to 6 days of childbirth and 12 weeks postpartum. Of the 308 young mothers, 57 (prevalence rate 19%) were identified as having been affected by RLS symptoms in the recently completed pregnancy. Structural and functional MRI was obtained from 25 of these 57 participants. A multivariate two-window algorithm was employed to systematically chart the relationship between brain structures and phenotypical predictors of RLS. A decreased volume of the parietal, orbitofrontal and frontal areas shortly after delivery was found to be linked to persistent RLS symptoms up to 12 weeks postpartum, the symptoms' severity and intensity in the most recent pregnancy, and a history of RLS in previous pregnancies. The same negative relationship was observed between brain volume and not being married, not receiving any iron supplement and higher numbers of stressful life events. High cortisol levels, being married and receiving iron supplements, on the other hand, were found to be associated with increased volumes in the bilateral striatum. Investigating RLS symptoms in pregnancy within a brain-phenotype framework may help shed light on the heterogeneity of the condition.

Zinc and Magnesium Levels of Pregnant Women with Restless Leg Syndrome and Their Relationship with Anxiety: A Case-Control Study

Restless leg syndrome (RLS) is a multifactorial movement disorder, and pregnancy is seen as a risk factor. This study aims to determine the clinical and psychiatric causes of RLS with a case-control study. The hemogram, biochemistry data, thyroid function tests, and serum element levels of healthy pregnant women (n = 134) and pregnant women diagnosed with RLS (n = 119) were compared. Total Ca, Mg, K, and Na concentrations were measured with an inductively coupled plasma optical emission spectrometry (ICP-OES), and an atomic absorption spectrophotometer was used to measure total concentrations of Zn in all samples. The Beck Anxiety Inventory (BAI), the Beck Depression Inventory (BDI), and the Pittsburg Sleep Quality Index (PSQI) scores were also compared in both groups. Sonographic measurements showed that the fetal biparietal diameter and femur lengths were higher in the RLS group (p = 0.001, p = 0.048, respectively), and abortion history was higher in the RLS group (p = 0.016). Magnesium and zinc levels were lower (p < 0.001 for both) and BAI and PSQI scores were higher (p < 0.001 for both) in the RLS group, and there was no difference between the BDI (p = 0.269) scores. A statistically significant relationship was detected between the BAI and RLS scores in the control and RLS groups (p < 0.001 for both). This is the first study to show that magnesium and zinc deficiency may play a role in the etiology of RLS during pregnancy; the results also showed adverse perinatal outcomes such as high miscarriage.

Lifestyle Medicine for Women: The Time Is Now!

As the founders of the American College of Lifestyle Medicine's Women's Health Member Interest Group, we welcome this issue focused on the important issues facing women, their providers, and researchers in this field. Women's health extends beyond sex-specific reproductive health issues, by also encompassing the medical conditions that are more prevalent in women as well as conditions that are expressed differently in women. Inadequate representation of women in clinical research has contributed to poorer outcomes. As lifestyle medicine forms the foundation of true health, the time is now to recognize and address these issues with research, education, and advocacy.

Unraveling the Mysteries of Restless Leg Syndrome

Restless leg syndrome (RLS) or Willis-Ekbom disease (WED) is an under-diagnosed, chronic, and progressive primary sensory-motor disorder. It is characterized by an uncontrollable urge to move the legs due to uncomfortable and sometimes painful sensations, with a diurnal variation. RLS can lead to severe sleep disturbances, a usual cause of consultation. The pathophysiology is known partially, and it is believed that there is an association between the different variants of genetic mutations combined with dopaminergic and brain iron dysregulation, which plays an important role. The data used for this study were extracted from the articles found in the PubMed database that discuss different gene variants, pathophysiology, and various methods of treatment. They also highlight the role of iron in the pathogenesis of RLS as it is required for the synthesis of tyrosine hydroxylase, which is the rate-limiting step for dopamine synthesis. This review article provides a clinically useful overview of RLS in terms of pathophysiological findings, its genetic associations, and therapeutic options by using the currently available literature. Because RLS presents with vague symptoms and shares similarities with many other diseases, it might be overlooked by many physicians resulting in underdiagnosis and under-treatment. While these discoveries provide a breakthrough in understanding the details of RLS, further studies are recommended as these studies are limited to animal models and provide a limited representation of the general population.

Management of Parkinson's disease and other movement disorders in women of childbearing age: Part 2

INTRODUCTION

Many diseases associated with hyperkinetic movement disorders manifest in women of childbearing age. It is important to understand the risks of these diseases during pregnancy, and the potential risks of treatment for the fetus.

OBJECTIVES

This study aims to define the clinical characteristics and the factors affecting the lives of women of childbearing age with dystonia, chorea, Tourette syndrome, tremor, and restless legs syndrome, and to establish guidelines for management of pregnancy and breastfeeding in these patients.

RESULTS

This consensus document was developed through an exhaustive literature search and a discussion of the content by a group of movement disorder experts from the Spanish Society of Neurology.

CONCLUSIONS

We must evaluate the risks and benefits of treatment in all women with hyperkinetic movement disorders, whether pre-existing or with onset during pregnancy, and aim to reduce effective doses as much as possible or to administer drugs only when necessary. In hereditary diseases, families should be offered genetic counselling. It is important to recognise movement disorders triggered during pregnancy, such as certain types of chorea and restless legs syndrome.

Restless Legs Syndrome During Pregnancy and 12 Weeks Postpartum and its Links to Cardiovascular Diseases, Stressful Life Events, and Psychiatric History

Restless legs syndrome (RLS) is highly prevalent among pregnant women. In the present study, a neurological-obstetrical sample of 561 postpartum women was retrospectively screened for RLS symptoms during pregnancy and in the first 12 weeks postpartum. The first screening took place within 1 to 6 days of delivery (T0) and the second 12 weeks after childbirth (T1). The pregnancy-related RLS prevalence rate was found to be 21% (n = 119), with the women suffering from RLS being more often affected by psychiatric history and having been more exposed to stressful life events. They were also found to have experienced baby blues more frequently shortly after childbirth. However, RLS in pregnancy did not appear to have any effect on the development of postpartum depression. Additionally, a positive trend was observed toward an association between pregnancy-related RLS and gestational diabetes and hypertension. Of the 119 women, 23 (19.3%) remained affected by RLS 12 weeks postpartum. Body mass index (BMI), weight gain, parity, childbearing history, or chronic stress exposure in pregnancy as measured by hair cortisol were not found to be linked to RLS. In summary, a comprehensive understanding of the interaction of clinical, environmental, and anamnestic factors can help shed valuable light on this pregnancy-related condition.

From Preconception Care to the First Day of School: Transforming the Health of New Families With Lifestyle Medicine

Lifestyle medicine holds great promise to transform health during the period from preconception to early childhood. Genetic, epigenetic, nutritional, and environmental factors have lifetime impact on the newborn and family. Little is known about the full potential of lifestyle medicine to improve maternal, child, and family health. Additionally, health care providers face limits in time and may have gaps in knowledge, that preclude discussion of the impact lifestyle medicine can the mother, newborn, and family. Greater understanding of the potential impact of lifestyle medicine provides opportunities to identify current deficiencies in care and areas for improvement and highlights the need for further research. This article reviews current evidence supporting the 6 pillars of lifestyle medicine: nutrition, physical activity, sleep, avoiding risky substance use, stress management and social connectedness as applied to maternal child care from preconception to early childhood, examines the current state of practice, and identifies opportunities for both practice change and further research. Rather than view each component of care in isolation, viewing care as a continuum from preconception to childhood can best establish healthy habits and optimize outcomes for the entire family.

Current Evidence on Diagnostic Criteria, Relevant Outcome Measures, and Efficacy of Nonpharmacologic Therapy in the Management of Restless Legs Syndrome (RLS): A Scoping Review

OBJECTIVE

The aim of this scoping review is to outline the current evidence regarding the management of restless legs syndrome (RLS) with nonpharmacologic approaches. To categorize the efficacy of conservative approaches in reducing symptoms of RLS, we have identified and summarized the current data regarding diagnostic criteria and relevant outcome measures, to inform future research and to guide clinical practice.

METHODS

A scoping review was conducted using the National Center for Biotechnology Information; EBSCO; the Manual, Alternative and Natural Therapy Index System; the Cumulative Index to Nursing & Allied Health Literature; and Scopus. All literature related to RLS was extracted, screened, and reviewed based on titles and abstract contents. The authors then extracted data from the 24 admissible studies, that is, the ones about manual therapy, exercises, and alternative treatments for RLS. The Physiotherapy Evidence Database scale was used to rate the methodological quality of the included randomized controlled trials by 2 independent readers.

RESULTS

In the 24 articles fulfilling the selection criteria, there was a consistent trend in the findings showing positive results in lowering RLS symptom severity. Most clinical studies based their diagnosis on the International Restless Legs Syndrome Study Group diagnostic criteria; the International Restless Legs Syndrome Study Group rating scale was the most often used outcome measure. The efficacy of exercise, yoga, massage, acupuncture, traction straight leg raise, cryotherapy, pneumatic compression devices, whole-body vibration, transcranial and transcutaneous stimulation, and near-infrared lights showed different effects on RLS symptom severity, and the level of evidence was evaluated.

CONCLUSION

Our results showed clinically significant effects for exercises, acupuncture, pneumatic compression devices, and near-infrared light. Short-lasting effects were identified with whole-body cryotherapy, repetitive transcranial stimulation, and transcutaneous stimulation. More studies are necessary to investigate efficacy of yoga, massage, traction straight leg raise, and whole-body vibration. No adverse effects were identified for moderate-intensity exercise, yoga, massage, and pneumatic compression devices.

Maternal and neonatal outcomes associated with restless legs syndrome in pregnancy: A systematic review

Restless legs syndrome (RLS) affects one in five pregnant women. This review aims to synthesise evidence regarding gestational RLS and its consequences on pregnant women and neonates. Search of Embase, MEDLINE, PsycINFO, Maternity and Infant Care and Scopus was conducted in July 2018 using MeSH headings and keywords for 'restless legs syndrome' and 'pregnancy' or 'birth'. Our search identified 16 eligible studies from 12 countries published between 2004 and 2018 concerning gestational RLS and one or more maternal, delivery or neonatal outcomes. The most consistent associations were observed between gestational RLS and increased risks of gestational hypertension, pre-eclampsia, and peripartum depression. There were mixed findings for caesarean delivery, preterm birth and low birth weight, with the majority reporting no association with gestational RLS. Gestational RLS was not associated with postpartum haemorrhage, gestational diabetes, fetal distress, or low Apgar scores. Future research is needed to investigate whether effective treatment of RLS can mitigate these potential harms. Validated methods for diagnosing RLS in pregnancy would support research in this growing field.

Thermo-therapy and cryotherapy to decrease the symptoms of restless leg syndrome during the pregnancy: A randomized clinical trial

BACKGROUND AND PURPOSE

Restless legs syndrome (RLS) is a common sensory-motor disorder among the pregnant women. The aim of this study is to compare the impacts of two methods of immersion of legs in cold and warm water on the RLS symptoms among the pregnant women.

METHODS

This randomized clinical trial was conducted on 80 pregnant women with RLS who referred to Taleghani educational-therapy center. After obtaining their informed consent, they were selected by accessible method and randomly allocated into group 1 (warm water) and group 2 (cold water). Group 1 were asked to put their legs in cold water for 10 min every night for 2 weeks. The group 2 put their legs in warm water under the same condition. The severity of RLS was measured before and after the study. Data analysis was conducted using descriptive as well as the analytical statistics such as Chi-square, independent T test, pair T test, Mann-Whitney U, Wilcoxon and covariance.

RESULTS

After intervention, mean RLS of the cold water group was11.02 ± 4.93; while this mean was 13.50 ± 4.74 in the warm water group. The difference between the two groups was significant (p = 0.017). Results also revealed that the severity of RLS symptoms at the end of the treatment was different from the beginning of the research in both groups (p = 0.001). The intervention with both warm and cold water declined the RLS symptoms among pregnant women.

CONCLUSION

The warm and cold water can be used for this purpose depending on the women's preference. However, this article recommends the cold water for more reducing of symptoms.

Frequency of iron deficiency anemia in pregnant and non-pregnant women suffering from restless legs syndrome

Objectives. Restless Legs Syndrome is a movement disorder characterized by unpleasant sensations in the legs described as a burning, tingling, etc. Symptoms become worse in the evening and are relieved by moving the limbs. The idiopathic form of the disease is associated with a lack of dopamine, and the secondary form is associated with iron deficiency anemia, pregnancy, and kidney disease. The aim of this study was to investigate the incidence of iron deficiency anemia in pregnant women and non-pregnant women suffering from RLS.Methods. The study was conducted on a sample of 231 pregnant women aged 18-50. The pregnant women were interviewed at the outpatient clinic of the Department of Gynaecology and Obstetrics. This study also included a control group of 231 age-compatible non-pregnant women. Women who met the international criteria for diagnosing the syndrome filled in a sociodemographic questionnaire.Results. A statistically significant association between the existence of iron deficiency anemia and RLS in the sample of the examined women was proven (p < 0.001). It was also shown that RLS is more frequent in a sample of anemic pregnant women than non-anemic pregnant women (p = 0.008).Conclusion. Iron deficiency anemia is related with RLS. Pregnant women with RLS are more likely to be anemic than pregnant women without RLS.

Sleep quality and restless leg syndrome among antenatal women attending government healthcare facilities in urban bangalore

Introduction:

Sleep changes are more common in pregnancy and lack of sleep in antenatal women can lead to hypertension, postpartum depression, abortions, and preterm babies.

Objectives:

1. To assess sleep quality and daytime sleepiness among pregnant women attending government health care facilities in Urban Bangalore. 2 To measure the association between sleep quality, daytime sleepiness with restless leg syndrome (RLS) in the same study population.

Methodology:

A cross-sectional study was conducted in March and April 2018 among all antenatal women attending the Government District Hospital, Anekal Taluk and Primary Health Centre, Sarjapur, in Urban Bangalore. The calculated sample size was 255 and we interviewed 260 women using the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale and RLS rating scale along with details on socio-demography.

Results:

According to PSQI, 83.1% had good sleep quality, 14.2% had daytime sleepiness and 21.9% had RLS. The RLS was significantly associated (P < 0.05) with trimester, sleep onset position, sleep quality, and daytime sleepiness. On logistic regression, there are 3.6 times the chances of having RLS when the sleep quality is bad and 5.3 times more chances of having RLS when there is daytime sleepiness.

Conclusion:

RLS is significantly associated with daytime sleepiness and sleep quality in antenatal women. Health education on the importance of sleep and about RLS should be included during antenatal visits.

[Sleep disorders as one of the indicators of postpartum depression]

Postpartum depression in ICD-10 refers to mild mental and behavioral disorders associated with physiological disorders of the postpartum period F53.0. Diagnosis is based on criteria, one of which is sleep disorders. The objective of the review is to characterize the postpartum sleep disorders and to reflect their predictor value in the development of postpartum depression. Presomnic, intrasomnic and postsomnic disorders with negative consequences for both the mother and her child were found in sleep disorders of women with postpartum depression. Depression with sleep disorders significantly affect the quality of life of the mother and infant. Sleep disorders are one of the predictors of postpartum depression. Improving of sleep quality is an effective way to prevent the effects of postpartum depression.

Restless Legs Syndrome in Pregnant Thai Women: Prevalence, Predictive Factors, and Natural Course

BACKGROUND AND PURPOSE

Restless legs syndrome (RLS) is a common sleep-related neurological disorder that affects the quality of sleep. This study aimed to estimate the prevalence, predictive factors, and natural course of RLS, and its effect on sleep quality in pregnant Thai women.

METHODS

A cross-sectional study that included 214 pregnant women was performed. RLS was diagnosed according to the revised criteria of the International RLS Study Group (IRLSSG). General demographic and antenatal-care data were reviewed. Scores on the Thai versions of the Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index, and the IRLSSG Rating Scale were determined.

RESULTS

RLS was diagnosed in 24 of the pregnant women (11.2%): 4.2%, 25.0%, and 70.8% in the first, second, and third trimesters, respectively. Multiple logistic regression analysis revealed that a hemoglobin level (Hb) less than 11 g/dL [odds ratio (OR)=3.21, 95% CI=1.27-8.13] and a history of RLS (OR=16.62, 95% CI=1.52-181.32) were associated with RLS during pregnancy. Subjects with RLS significantly had higher Thai-ESS scores (p<0.01). All subjects with RLS had severe symptoms that subsided within 1 week after delivery. No immediate labor complication was associated with RLS.

CONCLUSIONS

Our study has confirmed a high prevalence of RLS and its impacts on sleep in pregnant women. An Hb of less than 11 g/dL and a history of RLS are predictive factors for RLS developing during pregnancy. Pregnancy-related RLS has a benign course and usually disappears within 1 week after delivery.

Management Strategies for Restless Legs Syndrome/Willis-Ekbom Disease During Pregnancy

Restless legs syndrome/Willis-Ekbom disease is a common disorder during pregnancy that may significantly impact on the health of affected women, leading to negative consequences in the short and long term. An accurate diagnosis helps to recognize the syndrome and choose the optimal therapeutic strategy, based on the characteristics and needs of the patient. This article summarizes the main treatment options recommended by the consensus clinical guidelines of the International Restless Legs Syndrome Study Group and provides a short guide to the management of restless leg syndrome during pregnancy in clinical practice.

A Review of Women's Neurology

Concern about what is best practice when caring for women with neurologic disease is a common clinical scenario. Therefore, knowledge about women's health issues and their intersection with neurologic disorders is imperative. This review will discuss the appropriate gender-based considerations in epilepsy, multiple sclerosis, migraine, autoimmune disease, sleep disorders, stroke, and paraneoplastic disorders.

Restless Legs Syndrome and Sleep-Wake Disturbances in Pregnancy

STUDY OBJECTIVES

To estimate the association of restless legs syndrome (RLS) and its frequency with sleep-wake disturbances in pregnancy.

METHODS

A cohort of 1,563 women in their third trimester of pregnancy were recruited from prenatal clinics between March 2007 and December 2010. Demographic, pregnancy, and delivery data were extracted from medical records and sleep information was collected with questionnaires. To diagnose RLS, we used standardized criteria of RLS symptoms and frequency that were developed by the International Restless Legs Study Group. Logistic regression models were constructed to investigate the association of RLS and its frequency with sleep-wake disturbances (poor sleep quality, daytime sleepiness, poor daytime function) and delivery outcomes.

RESULTS

Overall 36% of the pregnant women had RLS, and half had moderate to severe symptoms. Compared to women without RLS, those with RLS were more likely to have poor sleep quality (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.7-2.9), poor daytime function (OR 1.9, 95% CI 1.4-2.4), and excessive daytime sleepiness (OR 1.6, 95% CI 1.3-2.0). A dose-response relationship also was evident between RLS frequency and each of the sleep-wake disturbances. There was no evidence for any association between RLS and delivery outcomes.

CONCLUSIONS

RLS is a significant contributor to poor sleep quality, daytime sleepiness, and poor daytime function, all common and often debilitating conditions in pregnancy. Obstetric health care providers should be aware of these associations and screen women for RLS.

COMMENTARY

A commentary on this article appears in this issue on page 857.

Restless Legs Syndrome: From Pathophysiology to Clinical Diagnosis and Management

Restless legs syndrome (RLS), a common neurological sensorimotor disorder in western countries, has gained more and more attention in Asian countries. The prevalence of RLS is higher in older people and females. RLS is most commonly related to iron deficiency, pregnancy and uremia. The RLS symptoms show a significant circadian rhythm and a close relationship to periodic limb movements (PLMs) in clinical observations, while the pathophysiological pathways are still unknown. The diagnostic criteria have been revised in 2012 to improve the validity of RLS diagnosis. Recent studies have suggested an important role of iron decrease of brain in RLS pathophysiology. Dopaminergic (DA) system dysfunction in A11 cell groups has been recognized long ago from clinical treatment and autopsy. Nowadays, it is believed that iron dysfunction can affect DA system from different pathways and opioids have a protective effect on DA system. Several susceptible single nucleotide polymorphisms such as BTBD9 and MEIS1, which are thought to be involved in embryonic neuronal development, have been reported to be associated with RLS. Several pharmacological and non-pharmacological treatment are discussed in this review. First-line treatments of RLS include DA agents and α2δ agonists. Augmentation is very common in long-term treatment of RLS which makes prevention and management of augmentation very important for RLS patients. A combination of different types of medication is effective in preventing and treating augmentation. The knowledge on RLS is still limited, the pathophysiology and better management of RLS remain to be discovered.

Restless legs syndrome and pregnancy: prevalence, possible pathophysiological mechanisms and treatment

Restless legs syndrome (RLS) is a common sleep disorder that may be associated with pregnancy. Studies have found that the prevalence of RLS among pregnant women ranged from 10 to 34%. Typically, there is complete remission of symptoms soon after parturition; however, in some patients, they may continue postpartum. RLS has been shown to be associated with a number of complications in pregnancy including preeclampsia and increased incidence of Cesarean sections. Although multiple hypotheses have been proposed to explain this association, each individual hypothesis cannot completely explain the whole pathogenesis. Present understanding suggests that a strong family history, low serum iron and ferritin level, and high estrogen level during pregnancy might play important roles. Vitamin D deficiency and calcium metabolism may also play a role. Medical treatment of RLS during pregnancy is difficult and challenging considering the risks to mother and fetus. However, in some cases, the disease may be severe enough to require treatment.

The Relationship of Restless Legs Syndrome to History of Pregnancy-Induced Hypertension

BACKGROUND

Restless legs syndrome (RLS), a burdensome sleep disorder, has been associated with cardiovascular disease (CVD), hypertension, diabetes, and related disorders. However, the relationship of RLS to history of pregnancy-induced hypertension (PIH), a predictor of subsequent CVD, diabetes, and associated conditions, remains little explored. In this study, we investigated the relationship of RLS to history of PIH in a sample of primary care patients.

METHODS

Participants were women aged ≥40 years drawn from an anonymous survey study of West Virginia primary care patients. Data collected included detailed information on demographics, lifestyle factors, sleep patterns, and reproductive/medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or unsure about their pregnancy status were excluded from the analyses.

RESULTS

Of the 498 participants in the final analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms ≥once/week, 11.9% with symptoms ≥3 times/week); 73 (16.5% of parous women) reported a history of PIH, defined as physician-diagnosed preeclampsia or gestational hypertension. After adjustment for demographics, lifestyle characteristics, obesity, reproductive history, health conditions, and other factors, those reporting a history of PIH were approximately twice as likely to meet criteria for RLS (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.1, 3.6). These associations increased in magnitude with increasing symptom frequency (adjusted OR for RLS with symptoms ≥3 times/week = 3.8; CI 1.9, 7.6; p for trend = 0.003).

CONCLUSIONS

History of PIH was strongly and positively related to current RLS in this study of primary care patients; these findings further support a possible role for metabolic dysregulation in RLS etiology.

Sleep Trajectories of Women Undergoing Elective Cesarean Section: Effects on Body Weight and Psychological Well-Being

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.

Restless legs syndrome and pregnancy or delivery complications in China: a representative survey

OBJECTIVE

To perform a detailed epidemiological study of Chinese women and the relationship between restless legs syndrome (RLS) in pregnancy and any associated complications during delivery.

METHODS

A total of 3874 pregnant women (18-40 years) who had delivered babies at The First Affiliated Hospital of Zhengzhou University from May 2011 to May 2014 were enrolled in the study. Using a face-to-face interview questionnaire, data were collected pertaining to RLS incidence in pregnancy and any associated complications during delivery. The relationship between RLS frequency and pregnancy or delivery complications was further investigated.

RESULTS

Among 12.3% of the eligible participants, RLS prevalence occurred at least weekly. Older pregnant women were more likely to suffer from RLS. Individuals who experienced RLS at least weekly reported a statistically higher frequency of excessive daytime sleepiness and an increased prevalence of hypertension, cardiovascular disease, and preeclampsia compared with those without RLS.

CONCLUSION

The study revealed that RLS was frequent in Chinese pregnant women, especially in those with pregnancy or delivery complications such as hypertension, cardiovascular disease, and preeclampsia. Restless legs syndrome was also associated with excessive daytime sleepiness.

Restless legs syndrome: clinical presentation diagnosis and treatment

Restless legs syndrome (RLS) is a circadian disorder of sensory-motor integration that may be related to genetically determined dysregulation of iron transport across the blood-brain barrier. Dopamine agonists (DAs) have been considered the first-line therapy, but with the growing appreciation of problems associated with long-term treatment, particularly augmentation and impulse control disorder, alpha-2-delta drugs, such as gabapentin, are now considered the first line of treatment in patients with troublesome RLS. Opioids can be considered as an alternative therapy, particularly in patients with DA-related augmentation. In more severe cases, a combination therapy may be required. Intravenous iron therapy may be considered on those patients with refractory RLS.

Pharmacological treatment of sleep disorders and its relationship with neuroplasticity

Sleep and wakefulness are regulated by complex brain circuits located in the brain stem, thalamus, subthalamus, hypothalamus, basal forebrain, and cerebral cortex. Wakefulness and NREM and REM sleep are modulated by the interactions between neurotransmitters that promote arousal and neurotransmitters that promote sleep. Various lines of evidence suggest that sleep disorders may negatively affect neuronal plasticity and cognitive function. Pharmacological treatments may alleviate these effects but may also have adverse side effects by themselves. This chapter discusses the relationship between sleep disorders, pharmacological treatments, and brain plasticity, including the treatment of insomnia, hypersomnias such as narcolepsy, restless legs syndrome (RLS), obstructive sleep apnea (OSA), and parasomnias.

Restless legs syndrome among pregnant women in China: prevalence and risk factors

BACKGROUND

The goal of this study was to identify the prevalence and clinical correlates and severity of restless legs syndrome (RLS) among pregnant women in mainland China.

METHODS

This cross-sectional study enrolled 1584 women (18-40 years old) who came to a prenatal outpatient clinic to consult an obstetrician. Pregnant women were studied in each trimester, and assessments included interviews about RLS symptoms and related questions. Standardized questionnaires include the International Restless Syndrome Scale and the Pittsburgh Sleep Quality Questionnaire. Blood tests included levels of hemoglobin and mean corpuscular volume.

RESULTS

RLS was diagnosed in 177 of 1584 women (11.2%); 4.2% were categorized as having pre-existing RLS and 54.8% reported onset of RLS symptoms after the 24th week. Multivariate analysis revealed that anemia was positively correlated with RLS. For the participants who first experienced RLS in pregnancy, RLS severity in the third trimester was more severe when compared with the first and second trimesters. Sleep disorders occurred more frequently in the third trimester.

CONCLUSIONS

In our study, RLS was frequent in pregnant Chinese women, and anemia was identified as an independent predictor of the disease. Further, most participants reported their symptoms during the third trimester, and the severity of RLS and sleep disorders of participants was more prominent in the third trimester.