Obstructive sleep apnea in pregnancy is associated with adverse maternal outcomes: a national cohort

Lymphangioleiomyomatosis and Pregnancy-Do We Have All the Answers for a Woman Who Desires to Conceive?-Literature Review

Lymphangioleiomyomatosis (LAM) is a rare, progressive, and poor-prognosis systemic disorder that primarily affects women of reproductive age, with a higher prevalence among individuals of Caucasian origin. However, there are limited reliable data on the prevalence of LAM during pregnancy. The fulminant respiratory clinical presentation that often includes progressive dyspnea on exertion, cough, or hemoptysis, frequently complicated by pneumothorax, and the increased risk of spontaneous abortion due to increased estrogen and progesterone production during gestation, are arguments that most often make the diagnosed woman avoid pregnancy. Elevated levels of vascular endothelial growth factor D (VEGF-D), decline in respiratory function, and radiological findings are sufficient arguments in favor of the diagnosis in the pregnant woman. Sirolimus, an mTOR inhibitor, has demonstrated effectiveness in slowing the decline of lung function. Although sirolimus treatment is often recommended to be discontinued before conception due to the increased risk of fetal growth restriction, maintaining a dose level of <5 pcg/mL, with serum drug levels of 3-5 pcg/L, has been considered safe. Given the potential risks, individualized decisions about pregnancy are advised for patients with LAM. For those who choose to proceed, close monitoring by a multidisciplinary team is essential to manage complications effectively. Ongoing research aims to provide clearer guidance to optimize outcomes for both mother and child.

Non-Pharmacological Sleep Interventions after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

AIM

To synthesise up-to-date research evidence for non-pharmacological interventions to improve various sleep outcomes (e.g., sleep quality, duration) in postsurgical cardiac patients.

BACKGROUND

Sleep disturbances are common amongst postsurgical cardiac patients, yet the effectiveness of non-pharmacological interventions in improving various sleep outcomes has not been comprehensively reviewed.

DESIGN

A systematic review and meta-analysis guided by the PRISMA protocol.

METHODS

CINAHL, PubMed, PsycINFO, Embase, Web of Science, and Cochrane Library were searched for relevant research in May 2023. Included studies used a randomised controlled trial design that applied a non-pharmacological intervention for postsurgical cardiac patients and reported sleep as an outcome. For the meta-analysis, mean effect sizes were separately calculated for studies with regular and reverse-scored scales.

RESULTS

Of 37 studies included, the most common cardiac surgery was coronary artery bypass graft. Most interventions were performed within the first postoperative week and assessed sleep quality outcomes using the Pittsburgh Sleep Quality Index. The interventions are categorised into five types. Human resource-based strategies emerged as the most effective. The meta-analysis of 27 eligible studies showed a mean effect size of 0.76 for studies with regular scoring scales and - 1.04 for those with reverse-scored scales, indicating medium to large effect sizes.

CONCLUSION

Our findings provide strong evidence that non-pharmacological interventions, particularly human resource-based strategies, significantly improve sleep quality in postsurgical cardiac patients. The medium to large effect sizes underscore the clinical significance of these findings.

IMPLICATIONS

Healthcare professionals should consider incorporating non-pharmacological interventions, especially human resource-based strategies, in care plans for postsurgical cardiac patients to improve sleep outcomes and promote recovery. These interventions should be tailored to individual physical and cultural differences for maximum effectiveness. Future research should evaluate the long-term effects of these interventions on various sleep outcomes, using both objective and subjective measures to provide a comprehensive assessment of their efficacy.

REPORTING METHOD

This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.

NO PATIENT OR PUBLIC CONTRIBUTION

Patient and public contributions were not required for this review.

[Obstructive apnea hypopnea syndrome in pregnancy]

Obstructive sleep apnea hypopnea syndrome (OSA) in pregnant women is an under-diagnosed but common condition, due to the numerous physiological changes favoring upper airway collapse. Risk factors such as significant weight gain during the 1st trimester, maternal age and parity should be systematically investigated. Diagnosis is made by sleep recording. OSA can lead to maternal and fetal complications (gestational diabetes, eclampsia, intrauterine growth restriction, prematurity…) during pregnancy, delivery and the post-partum period. It is therefore essential to treat apneic patients as early as possible in pregnancy. Treatment includes hygienic and dietary measures, as well as continuous positive airway pressure (CPAP). Systematic post-partum follow-up with polygraphic monitoring should be proposed.

Pregnancy-onset obstructive sleep apnea and ambulatory blood pressure

STUDY OBJECTIVE

Elevated nocturnal blood pressure (BP) increases the risk for hypertensive disorders of pregnancy (HDP). Though obstructive sleep apnea (OSA) increases the risk for HDP, data on OSA and 24-hour ambulatory blood pressure monitoring (ABPM) in pregnancy are scarce. We aim to examine the BP profile of women with pregnancy-onset OSA.

METHODS

Pregnant women with overweight / obesity and snoring were recruited at <13 weeks gestation and underwent level III home sleep apnea testing and 24-hour ABPM at enrollment and at 31-34 weeks' gestation. Women with OSA at enrollment were excluded . Mean differences in nocturnal BP and 24-hour BP measurements, between women with pregnancy-onset OSA and women without OSA, were computed by multivariable linear regression.

RESULTS

40 / 101 participants had pregnancy-onset OSA (respiratory event index (REI) >5 events per hour) in the third trimester. Despite no significant differences in baseline BP, nocturnal systolic and diastolic BP were significantly higher in women with pregnancy-onset OSA compared to women without OSA, after adjusting for multiple covariates (mean difference 5.49 (1.45-9.52) and 3.89 (0.19-7.60), respectively). Differences in systolic BP persisted into the daytime in the OSA group. Lack of nocturnal dipping was highly prevalent in both groups, but the difference was not significant in the adjusted model.

CONCLUSION

Pregnancy-onset OSA in the 3rd trimester is associated with elevated nocturnal BP and daytime systolic BP. The lack of nocturnal dipping irrespective of REI cut-off in pregnant women at risk for SDB further demonstrates limitations of REI in defining pathology in pregnancy.

Obstructive sleep apnea in pregnancy: A review of the literature from the obstetrics practitioner's view and a proposed clinical approach

Obstructive sleep apnea (OSA) is a frequent condition during pregnancy and its occurrence is increased in obese women. There are growing concerns about both pre-existing OSA and the development of gestational OSA and their effect on maternal pregnancy outcomes, fetal development, and even early childhood. A strong body of research has revealed maternal complications of OSA, but far fewer studies explore its impact on the developing fetus, highlighting an important area of future research. As evidence in both areas mounts about the negative reproductive impact of OSA, studies have emerged that explore the limitations of current diagnostic criteria and screening tools for this disorder in pregnancy which, in turn, limit the practitioner's ability to appropriately refer patients for OSA diagnosis and treatment. This expert review summarizes the current data regarding OSA screening tools in pregnancy, the limitations of these tools, and available OSA treatments and their efficacies. Our objective is to develop recommendations for how to best screen and manage OSA in pregnancy. We conclude that improved understanding of available tools and treatments will allow the obstetric practitioner to better counsel patients and help mitigate the deleterious effects of OSA on mother and fetus. We herein propose a clinical approach for the screening and management of OSA in pregnancy.

Continuous Positive Airway Pressure Treatment and Hypertensive Adverse Outcomes in Pregnancy: A Systematic Review and Meta-Analysis

Importance

Pregnancy may contribute to the development or exacerbation of obstructive sleep apnea (OSA) and increase the risk of gestational complications. Continuous positive airway pressure (CPAP) is the first-line and criterion standard treatment for OSA and is regarded as the most feasible choice during pregnancy. However, the association between CPAP therapy in pregnant women with OSA and reduced gestational complications remains inconclusive.

Objective

To investigate the association between CPAP therapy in pregnant women with OSA and the reduction of adverse hypertensive outcomes during gestation.

Data Sources

Keyword searches of PubMed, Embase, and the Cochrane Database of Systematic Reviews and Clinical Trials were conducted from inception to November 5, 2023.

Study Selection

Original studies reporting the treatment effect of CPAP use on lowering hypertension and preeclampsia risks in pregnant women with OSA were selected.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed in the reporting of reviews. Data were independently extracted by 2 authors. Random-effects model meta-analyses were performed and risk ratios (RRs) reported. Subgroup analysis, meta-regression based on age and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), and publication bias assessment were also conducted.

Main Outcome and Measures

The primary outcome was the RR of gestational hypertension and preeclampsia between pregnant women with OSA receiving CPAP treatment and those who did not receive CPAP treatment.

Results

Six original studies in 809 participants (mean age, 31.4 years; mean BMI, 34.0) were identified and systematically reviewed for meta-analysis. The pooled results showed significant differences between the intervention (CPAP use) and the control (non-CPAP use) groups in reducing the risk of gestational hypertension (RR, 0.65; 95% CI, 0.47-0.89; P = .008) and preeclampsia (RR, 0.70; 95% CI, 0.50-0.98; P = .04). Meta-regression revealed that patients' age (coefficient, -0.0190; P = .83) and BMI (coefficient, -0.0042; P = .87) were not correlated with reduction of risk of hypertension and preeclampsia.

Conclusions and Relevance

These findings suggest that implementing CPAP treatment in pregnant women with OSA may reduce the risk of gestational hypertension and preeclampsia.

Urolithin A, induces apoptosis and autophagy crosstalk in Oral Squamous Cell Carcinoma via mTOR /AKT/ERK1/2 pathway

BACKGROUND

Oral squamous cell carcinoma (OSCC) is the most prevalent malignancy in the world with an alarming rate of mortality. Despite the advancement in treatment strategies and drug developments, the overall survival rate remains poor. Therefore, it is imperative to develop alternative or complimentary anti cancer drugs with minimum off target effects. Urolithin A, a microbial metabolite of ellagic acid and ellagitannins produced endogenously by human gut micro biome is considered to have anti-cancerous activity. However anti tumorigenic effect of urolithin A in OSCC is yet to be elucidated. In this study, we examined whether urolithin A inhibits cell growth and induces both apoptosis and autophagy dependent cell death in OSCC cell lines.

PURPOSE

The present study aims to evaluate the potential of urolithin A to inhibit OSCC and its regulatory effect on OSCC proliferation and invasion in vitro and in vivo mouse models.

METHODS

We evaluated whether urolithin A could induce cell death in OSCC in vitro and in vivo mouse models.

RESULTS

Flow cytometric and immunoblot analysis on Urolithin A treated OSCC cell lines revealed that urolithin A markedly induced cell death of OSCC via the induction of endoplasmic reticulum stress and subsequent inhibition of AKT and mTOR signaling as evidenced by decreased levels of phosphorylated mTOR and 4EBP1. This further revealed a possible cross talk between apoptotic and autophagic signaling pathways. In vivo study demonstrated that urolithin A treatment reduced tumor size and showed a decrease in mTOR, ERK1/2 and Akt levels along with a decrease in proliferation marker, Ki67. Taken together, in vitro as well as our in vivo data indicates that urolithin A is a potential anticancer agent and the inhibition of AKT/mTOR/ERK signalling is crucial in Urolithin A induced growth suppression in oral cancer.

CONCLUSION

Urolithin A exerts its anti tumorigenic activity through the induction of apoptotic and autophagy pathways in OSCC. Our findings suggest that urolithin A markedly induced cell death of oral squamous cell carcinoma via the induction of endoplasmic reticulum stress and subsequent inhibition of AKT and mTOR signaling as evidenced by decreased levels of phosphorylated mTOR and 4EBP1. Urolithin A remarkably suppressed tumor growth in both in vitro and in vivo mouse models signifying its potential as an anticancer agent in the prevention and treatment of OSCC. Henceforth, our findings provide a new insight into the therapeutic potential of urolithin A in the prevention and treatment of OSCC.

Sex Differences in Obstructive Sleep Apnea Including Pregnancy and Response to Treatment

This article highlights the sex differences in obstructive sleep apnea (OSA) and sheds light on the varying presentations, diagnostic challenges, as well as treatment responses observed in men and women. The disparities in prevalence, manifestations, and therapeutic outcomes underscore the need for a nuanced approach to OSA diagnosis and management that considers sex-specific factors. Furthermore, this article highlights the importance of recognizing and treating OSA during pregnancy, as it poses unique challenges and potential risks to both maternal and fetal health.

Atrial fibrillation considerations in the fourth trimester (postpartum period)

Postpartum atrial fibrillation is an uncommon but increasingly prevalent tachyarrhythmia that merits special management considerations with regards to the safety and efficacy of anticoagulation, rate and rhythm control as well as drug exposure to infants throughout breastfeeding. In this state-of-the-art review, we examine the demographics of postpartum atrial fibrillation with its associated risk factors, describe the safety of commonly used atrial fibrillation therapies, and discuss important considerations for women considering subsequent pregnancies.

Effect of Obstructive Sleep Apnea during Pregnancy on Fetal Development: Gene Expression Profile of Cord Blood

Obstructive sleep apnea (OSA) is quite prevalent during pregnancy and is associated with adverse perinatal outcomes, but its potential influence on fetal development remains unclear. This study investigated maternal OSA impact on the fetus by analyzing gene expression profiles in whole cord blood (WCB). Ten women in the third trimester of pregnancy were included, five OSA and five non-OSA cases. WCB RNA expression was analyzed by microarray technology to identify differentially expressed genes (DEGs) under OSA conditions. After data normalization, 3238 genes showed significant differential expression under OSA conditions, with 2690 upregulated genes and 548 downregulated genes. Functional enrichment was conducted using gene set enrichment analysis (GSEA) applied to Gene Ontology annotations. Key biological processes involved in OSA were identified, including response to oxidative stress and hypoxia, apoptosis, insulin response and secretion, and placental development. Moreover, DEGs were confirmed through qPCR analyses in additional WCB samples (7 with OSA and 13 without OSA). This highlighted differential expression of several genes in OSA (EGR1, PFN1 and PRKAR1A), with distinct gene expression profiles observed during rapid eye movement (REM)-OSA in pregnancy (PFN1, UBA52, EGR1, STX4, MYC, JUNB, and MAPKAP). These findings suggest that OSA, particularly during REM sleep, may negatively impact various biological processes during fetal development.

Obstructive Sleep Apnea in Pregnancy: A Comprehensive Review of Maternal and Fetal Implications

Obstructive sleep apnea (OSA) is a prevalent yet underdiagnosed condition in pregnancy, associated with various maternal and fetal complications. This review synthesizes the current evidence on the epidemiology, pathophysiology, and neurological consequences of OSA in pregnancy, along with the potential management strategies. Articles were sourced from the PubMed, EMBASE, and Cochrane databases until 2023. Our comprehensive review highlights that the incidence of OSA increases during pregnancy due to physiological changes such as weight gain and hormonal fluctuations. OSA in pregnancy is linked with gestational hypertension, pre-eclampsia, gestational diabetes, and potential adverse fetal outcomes such as intrauterine growth restriction and preterm birth. Continuous positive airway pressure (CPAP) therapy remains the most effective management strategy for pregnant women with OSA. However, adherence to CPAP therapy is often suboptimal. This comprehensive review underscores the importance of the early recognition, timely diagnosis, and effective management of OSA in pregnancy to improve both maternal and fetal outcomes. Future research should focus on enhancing screening strategies and improving adherence to CPAP therapy in this population.

Tandem Mass Tag-Labeled Quantitative Proteome Analyses Identify C1R and A2M as Novel Serum Biomarkers in Pregnant Women with Obstructive Sleep Apnea

The aim of this study was to identify serum diagnostic biomarkers associated with the severity of obstructive sleep apnea (OSA) during pregnancy. Differentially expressed proteins (DEPs) were identified in the control (C), mild (O), and moderate (MO) OSA groups (n = 3 in each group). Bioinformatics analysis was conducted to identify the underlying functions, pathways, and networks of the proteins. Receiver operating characteristic curves were used to assess the diagnostic value of the identified DEPs. The enzyme-linked immunoassay was performed to detect serum levels of the complement C1r subcomponent (C1R) and alpha-2-macroglobulin (A2M) in 79 pregnant women with OSA (mild OSA [n = 32]; moderate OSA [n = 29], and severe OSA [n = 18]) and 65 healthy pregnant women without OSA. Pearson's correlation analysis was conducted to analyze the correlation between C1R and A2M levels and OSA clinicopathological factors. In total, 141 DEPs, 29 DEPs, and 103 DEPs were identified in the three groups (i.e., the mild OSA vs control group, the moderate OSA vs mild apnea group, and the moderate OSA vs control group, respectively). C1R and A2M were identified as continuously up-regulated proteins, and the levels of C1R and A2M were associated with OSA severity. C1R and A2M were found to be correlated with body mass index, systolic blood pressure, apnea-hypopnea index, oxygen desaturation index, time with saturation below 90%, and lowest SaO2. Adverse maternal and neonatal outcomes were observed in pregnant women with OSA. C1R and A2M have been identified as diagnostic biomarkers and are associated with the severity of OSA during pregnancy.

Referral practices and treatment of obstructive sleep apnea in pregnancies with obesity

Objective

Obstructive sleep apnea (OSA) affects maternal and neonatal health during pregnancy. This study aimed to identify characteristics and comorbidities associated with sleep clinic referral in high-risk pregnancies with Body Mass Index (BMI) ≥35 kg/m2.

Method

Retrospective cohort study for individuals in a high-risk pregnancy clinic at a tertiary Australian hospital from 1 January to 31 December 2020 with BMI≥35 kg/m2. The primary outcome measure was sleep clinic referral. Exposure data included multiple comorbidities and formal tools (Epworth Sleepiness Scale and STOP-BANG). Multivariable analysis was used to identify factors associated with referral. Descriptive data on barriers to diagnosis and treatment were collected.

Results

Of 161 pregnant individuals, 38.5% were screened using formal tools and 13.7% were referred to sleep clinic. Having STOP-BANG performed was associated with sleep clinic referral (Odds Ratio: 18.04, 95% Confidence Interval:4.5-71.7, p < 0.001). No clinical characteristics were associated with the likelihood of performing STOP-BANG. The COVID-19 pandemic was a treatment barrier for three individuals.

Conclusions

Current screening practices identify pregnant individuals with the highest pre-test probability of having OSA. Future research should evaluate real-world strategies to improve identification and management in this high-risk population.

Assessment of Sleep Quality in Spanish Twin Pregnancy: An Observational Single-Center Study

Women with twin pregnancies experience greater sleep disturbance compared to women with singleton pregnancies. The aims of this study were to explore the sleep quality in women with twin pregnancies and to compare their sleep dimensions with coetaneous single pregnancies. This was an observational study in which women were enrolled at the end of pregnancy in the Obstetric Service of Hospital La Paz (Spain). The women were classified as single (n = 143) or twin pregnancy (n = 62). Pregnant women responded to the Pittsburgh Sleep Quality Index to evaluate sleep quality, latency, duration, efficiency, perturbance, use of medication, and daytime dysfunction. The higher the index, the greater the alteration of sleep quality. Without statistical differences, a poor sleep quality was higher in women with single (66.7%) than women with twin pregnancies (22.8%). The good sleeper slept 6.8 h/day in single pregnancy and 7.3 h/day in twin pregnancy. The sleep perturbation and dysfunctionality were higher in women with twin than single pregnancies. The use of medication to sleep was significantly lower in women with twin than single pregnancies. In women with twin pregnancy, the body weight gain during first trimester had a positive correlation with worse sleep quality and sleep perturbations. Twin pregnancy needed more than 7 h/day to have a high sleep quality, showing greater sleep perturbations and daytime dysfunction than single pregnancies. The control of gestational body weight can improve the sleep quality, disturbances, and duration in twin gestations. Sleep screening during pregnancy would be necessary to handle sleep issues and increase benefits in twin gestational outcomes.

Longitudinally assessed maternal sleep position, measures of breathing during sleep, and fetal growth in high-risk pregnancies

STUDY OBJECTIVES

Subjective recall of supine sleep during pregnancy has been linked to increased risk of stillbirth, but longitudinal, objective data are lacking. We aimed to examine how sleep position and breathing parameters change throughout pregnancy, and investigated associations between maternal supine sleep, assessed objectively in early and late gestation, and fetal growth velocity in high-risk women.

METHODS

Women with singleton pregnancies and body mass index (BMI) ≥27 kg/m2 underwent level-III sleep apnea testing. Sleep position was assessed by accelerometry. We derived percentiles of estimated fetal weight and birthweight using FetalGPSR software, then calculated growth velocity as change in percentile/week between the second-trimester anatomy scan and birth.

RESULTS

In total, 446 women were included, with N = 126 in the longitudinal sleep pattern analysis and N = 83 in the fetal growth analysis. Sleep-onset position and predominant sleep position were significantly correlated in both early (p = 0.001) and late (p < 0.01) pregnancy. However, supine going-to-bed position predicted predominant supine sleep in only 47% of women. Between early and late pregnancy there was a reduction in predominant supine sleepers (51.6% to 30.2%). Percent of sleep spent supine and oxygen desaturation index, in the third trimester, were significantly associated after BMI adjustment (B = 0.018, p = 0.04). Models did not suggest significant effects of early or late pregnancy supine sleep on growth velocity (p > 0.05).

CONCLUSIONS

Going-to-bed position predicts predominant supine sleep in less than half of women with overweight and obesity. Time spent supine throughout pregnancy correlates with measures of sleep-disordered breathing. Maternal sleep position patterns did not affect fetal growth velocity in this high-risk population, but the study was not powered to detect differences.

Maternal sleep disordered breathing and offspring growth outcome: A systematic review and meta-analysis

Sleep disordered breathing is extremely common in pregnancy and is a risk factor for maternal complications. Animal models demonstrate that intermittent hypoxia causes abnormal fetal growth. However, there are conflicting data on the association between maternal sleep disordered breathing and offspring growth in humans. We investigated this association by conducting a systematic review and meta-analysis. Sixty-three manuscripts, and total study population of 67, 671, 110 pregnant women were included. Thirty-one studies used subjective methods to define sleep disordered breathing, 24 applied objective methods and eight used international codes. Using a random effects model, habitual snoring, defined by subjective methods, and obstructive sleep apnea, diagnosed by objective methods, were associated with an increased risk for large for gestational age (OR 1.46; 95%CI 1.02-2.09 and OR 2.19; 95%CI 1.63-2.95, respectively), while obstructive sleep apnea, identified by international codes, was associated with an increased risk for small for gestational age newborns (OR 1.28; 95%CI 1.02-1.60). Our results support that maternal sleep disordered breathing is associated with offspring growth, with differences related to the type of disorder and diagnostic methods used. Future studies should investigate underlying mechanisms and whether treatment of sleep disordered breathing ameliorates the neonatal growth.

Gestational intermittent hypoxia induces endothelial dysfunction and hypertension in pregnant rats: role of endothelin type B receptor†

Obstructive sleep apnea is a recognized risk factor for gestational hypertension, yet the exact mechanism behind this association remains unclear. Here, we tested the hypothesis that intermittent hypoxia, a hallmark of obstructive sleep apnea, induces gestational hypertension through perturbed endothelin-1 signaling. Pregnant Sprague-Dawley rats were subjected to normoxia (control), mild intermittent hypoxia (10.5% O2), or severe intermittent hypoxia (6.5% O2) from gestational days 10-21. Blood pressure was monitored. Plasma was collected and mesenteric arteries were isolated for myograph and protein analyses. The mild and severe intermittent hypoxia groups demonstrated elevated blood pressure, reduced plasma nitrate/nitrite, and unchanged endothelin-1 levels compared to the control group. Western blot analysis revealed decreased expression of endothelin type B receptor and phosphorylated endothelial nitric oxide synthase, while the levels of endothelin type A receptor and total endothelial nitric oxide synthase remained unchanged following intermittent hypoxia exposure. The contractile responses to potassium chloride, phenylephrine, and endothelin-1 were unaffected in endothelium-denuded arteries from mild and severe intermittent hypoxia rats. However, mild and severe intermittent hypoxia rats exhibited impaired endothelium-dependent vasorelaxation responses to endothelin type B receptor agonist IRL-1620 and acetylcholine compared to controls. Endothelium denudation abolished IRL-1620-induced vasorelaxation, supporting the involvement of endothelium in endothelin type B receptor-mediated relaxation. Treatment with IRL-1620 during intermittent hypoxia exposure significantly attenuated intermittent hypoxia-induced hypertension in pregnant rats. This was associated with elevated circulating nitrate/nitrite levels, enhanced endothelin type B receptor expression, increased endothelial nitric oxide synthase activation, and improved vasodilation responses. Our data suggested that intermittent hypoxia exposure during gestation increases blood pressure in pregnant rats by suppressing endothelin type B receptor-mediated signaling, providing a molecular mechanism linking intermittent hypoxia and gestational hypertension.

Diagnostic Value of Neutrophil to Lymphocyte Ratio for Assessing Obstructive Sleep Apnea Risk in Surgical Patients

PURPOSE

Obstructive sleep apnea (OSA) is an important risk factor leading to perioperative complications in surgical patients. Neutrophil-to-lymphocyte ratio (NLR) is an important biomarker of increasing interest in recent years, and is used in the determination of systemic inflammatory response.

DESIGN

The aim of this study was to evaluate the risk of OSA and the relationship between OSA risk and NLR in surgical patients.

METHODS

The study was conducted in a tertiary care hospital between November 2021 and May 2022. The cross-sectional study included 604 patients who underwent surgery. OSA risk was evaluated with the STOP-Bang questionnaire in the preoperative evaluation in all patients. NLR was calculated as the ratio of neutrophil count to lymphocyte count.

FINDINGS

According to the STOP-Bang questionnaire, 62.3% of the patients had a high risk of OSA in the preoperative period. Patients who were male, elderly, obese, had hypertension, diabetes, chronic lung disease, and heart disease and polypharmacy were at greater risk of OSA. Patients at high risk of OSA had significantly higher NLR than patients at low risk of OSA. (2.65 vs 2.92, P.ß=.ß.024). NLR of 2.40 or higher predicted OSA risk with 58.8% sensitivity and 51.0% specificity (AUC.ß=.ß0.561) CONCLUSIONS: Most patients who were to undergo surgery had a high risk of OSA. NLR was higher in patients at high risk of OSA. Although the diagnostic efficacy is not high, NLR can be used to detect high OSA risk because it is a low-cost and easy to obtain biomarker.

Home monitoring for clinically suspected obstructive sleep apnea in pregnancy

STUDY OBJECTIVES

To determine if a home sleep apnea test (HSAT) using a type III portable monitor (PM), Nox-T3 (Nox Medical, Inc., Reykjavik, Iceland), detects obstructive sleep apnea in pregnant women.

METHODS

Ninety-two pregnant women (34.5 ± 4.3 years; gestational age 25.4 ± 8.9 weeks; body mass index 29.9 ± 4.7 kg/m2) with suspected obstructive sleep apnea underwent HSAT with the Nox-T3 PM followed by overnight polysomnography (PSG) and PM recording simultaneously in the laboratory within 1 week. PMs were scored automatically and manually using a 3% criteria and compared with PSGs scored by following guidelines.

RESULTS

Apnea-hypopnea indexes were 8.56 ± 10.42, 8.19 ± 13.79, and 8.71 ± 14.19 events/h on HSAT, in-laboratory PM recording, and PSG (P = .955), respectively. Bland-Altman analysis of the apnea-hypopnea index on PSG vs HSAT showed a mean difference (95% confidence interval) of -0.15 (-1.83, 1.53); limits of agreement (± 2 SD) were -16.26 to 16.56 events/h. Based on a threshold apnea-hypopnea index ≥ 5 events/h, HSAT had 91% sensitivity, 85% specificity, 84% positive-predictive value, and 92% negative-predictive value compared with PSG. When comparing the simultaneous recordings, closer agreement was observed. Automated vs manual analysis of PM showed no significant difference.

CONCLUSIONS

A type III PM had an acceptable failure rate and high diagnostic performance operating as a reasonable alternative for in-laboratory PSG in pregnant women.

CITATION

Wang J, Zhang C, Xu L, et al. Home monitoring for clinically suspected obstructive sleep apnea in pregnancy. J Clin Sleep Med. 2023;19(11):1951-1960.

Common sleep disorders in pregnancy: a review

In this review, we provide a comprehensive overview of common sleep disorders during pregnancy, including their characterization, prevalence, risk factors, and possible contribution to maternal and fetal outcomes. We conducted a quasi-systematic literature search of the MEDLINE database and identified 744 studies from 1991 through 2021, inclusive, that met our inclusion criteria. We synthesized the existing literature on sleep disorders during pregnancy and highlighted controversies, research gaps, and needed clinical developments. Our review covers a range of sleep disorders, including insomnia, obstructive sleep apnea, restless legs syndrome, and circadian rhythm disorders. We discuss the prevalence of these disorders in pregnancy and their potential impact on maternal and fetal health outcomes. We also explore the relationship between sleep disorders, pre-pregnancy comorbidities such as obesity, and pregnancy-related conditions such as gestational diabetes mellitus and preeclampsia. In addition to summarizing the existing literature on sleep disorders during pregnancy, we also highlight opportunities for further research in this area. We suggest that future studies should strive to employ validated and objective measurement tools for sleep disorders and prioritize utilization of longitudinal methods with participant follow-up through postpartum, mid-life, menopause, and beyond. We also put forward investigation into the impact of circadian rhythm disruption on reproductive physiology and early pregnancy outcomes as an area of important work. Overall, our review provides valuable insights on sleep and reproduction and into common sleep disorders during pregnancy and their potential impact on maternal and fetal health outcomes.

Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology Consensus Guideline on the Screening, Diagnosis, and Treatment of Obstructive Sleep Apnea in Pregnancy

The Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology tasked an expert group to review existing evidence and to generate recommendations on the screening, diagnosis, and treatment of patients with obstructive sleep apnea during pregnancy. These recommendations are based on a systematic review of the available scientific evidence and expert opinion when scientific evidence is lacking. This guideline may not be appropriate for all clinical situations and patients, and physicians must decide whether these recommendations are appropriate for their patients on an individual basis. We recognize that not all pregnant people may identify as women. However, data on non-cisgendered pregnant patients are lacking, and many published studies use gender-binary terms; therefore, depending on the study referenced, we may refer to pregnant individuals as women. This guideline may inform the creation of clinical protocols by individual institutions that consider the unique considerations of their patient populations and the available resources.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.

A Systematic Review of Studies Examining Associations between Sleep Characteristics with Dietary Intake and Eating Behaviors during Pregnancy

Little is known about the association between sleep and diet in pregnancy, despite both behaviors impacting maternal and fetal health. We aimed to perform a systematic review of the available literature on associations between sleep characteristics and dietary intake and eating behaviors during pregnancy, reporting on both maternal and fetal outcomes. We followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and conducted our search on 27 May 2021 in the PubMed, EMBASE, and CINAHL databases. The search yielded 6785 unique articles, of which 25 met our eligibility criteria. The studies, mostly observational, published 1993-2021, include data from 168,665 participants. Studies included examinations of associations between various maternal sleep measures with a diverse set of diet-related measures, including energy or nutrient intake (N = 12), dietary patterns (N = 9), and eating behaviors (N = 11). Associations of maternal exposures with fetal/infant outcomes were also examined (N = 5). We observed considerable heterogeneity across studies precluding our ability to perform a meta-analysis or form strong conclusions; however, several studies did report significant findings. Results from this systematic review demonstrate the need for consistency in methods across studies to better understand relationships between diet and sleep characteristics during pregnancy.

Sex and Gender in Lung Diseases and Sleep Disorders: A State-of-the-Art Review: Part 2

There is now ample evidence that differences in sex and gender contribute to the incidence, susceptibility, presentation, diagnosis, and clinical course of many lung diseases. Some conditions are more prevalent in women, such as pulmonary arterial hypertension and sarcoidosis. Some life stages-such as pregnancy-are unique to women and can affect the onset and course of lung disease. Clinical presentation may differ as well, such as the higher number of exacerbations experienced by women with cystic fibrosis (CF), more fatigue in women with sarcoidosis, and more difficulty in achieving smoking cessation. Outcomes such as mortality may be different as well, as indicated by the higher mortality in women with CF. In addition, response to therapy and medication safety may also differ by sex, and yet, pharmacogenomic factors are often not adequately addressed in clinical trials. Various aspects of lung/sleep biology and pathobiology are impacted by female sex and female reproductive transitions. Differential gene expression or organ development can be impacted by these biological differences. Understanding these differences is the first step in moving toward precision medicine for all patients. This article is the second part of a state-of-the-art review of specific effects of sex and gender focused on epidemiology, disease presentation, risk factors, and management of selected lung diseases. We review the more recent literature and focus on guidelines incorporating sex and gender differences in pulmonary hypertension, CF and non-CF bronchiectasis, sarcoidosis, restless legs syndrome and insomnia, and critical illness. We also provide a summary of the effects of pregnancy on lung diseases and discuss the impact of sex and gender on tobacco use and treatment of nicotine use disorder.

Obstructive Sleep Apnea Among Gravidas With Chronic Hypertension Compared to Matched Controls: A Prospective Cohort Study

BACKGROUND

Previous studies of obstructive sleep apnea (OSA) risk in gravidas with chronic hypertension (cHTN) did not control for obesity as a risk factor for OSA. We therefore performed this study to evaluate whether OSA is more prevalent among gravidas with cHTN compared to normotensive gravidas matched for body mass index (BMI) and gestational age (primary outcome). We also assessed whether OSA is more severe when comorbid with cHTN in pregnancy (secondary outcome).

METHODS

This was a single-center, prospective cohort study. Adult gravidas at 10-20 weeks of gestation, with and without cHTN, were enrolled and BMI matched. All subjects answered OSA screening questionnaires and underwent a home sleep test when they were between 10 and 20 weeks of gestation. Pregnancy outcomes were followed for all subjects. We performed univariable and multivariable logistic regression to model the relationship between cHTN status and OSA.

RESULTS

A total of 100 pregnant subjects (50 with cHTN and 50 normotensive) completed a home sleep test of 2 hours or more. There were no differences in demographic variables between the 2 groups, except that gravidas with cHTN were significantly older than normotensive subjects (mean ± standard deviation [SD] 34 ± 4 vs 30 ± 6 years; P < .001). OSA was more prevalent (64% vs 38%; P = .009; odds ratio [95% confidence interval (CI)] 2.90 [1.30-6.65]; P = .01) and more severe in gravidas with cHTN (moderate or severe OSA 59% vs 21%; P = .009). After controlling for age, we found no overall association between cHTN on OSA risk (adjusted odds ratio [95% CI] 2.22 [0.92-5.40]; P = .076). However, among gravidas older than 25 years of age, cHTN was associated with higher odds of OSA (adjusted odds ratio [95% CI], 2.64 [1.06-6.71], P = .038).

CONCLUSIONS

cHTN and age are important risk factors for OSA in gravidas. Gravidas with cHTN should be screened for OSA in early pregnancy. Future studies may validate screening tools that include cHTN and age, and investigate the role of OSA therapy in blood pressure control.

Longitudinal Sleep Study in Pregnancy: Cohort Profile and Prevalence and Risk Factors for Sleep Symptoms in the First Trimester

Sleep disorders could influence pregnancy outcomes but evidence for longitudinal associations is scarce. We established a prospective cohort of women to determine incident sleep issues and their adverse health outcomes during pregnancy and beyond, and present here the baseline cohort profile. Antenatal women in gestational weeks 8-12 were recruited (n = 535) and followed-up in each trimester and at 5-6 weeks postpartum (no attrition). Sleep symptoms and disorders were measured using STOP-Bang and Berlin questionnaires and Pittsburgh Sleep Quality Index. Incident health outcomes were extracted from clinical records. At the time of recruitment, habitual snoring was present in 13.8% of participants; "excessive sleepiness during the day" (EDS) in 42.8%; short (<7 h) sleep duration in 46.4%; "having trouble sleeping" in 15.3%; and "poor subjective sleep quality" in 8.6%. Habitual snoring was strongly associated with irregular menstrual periods for one year preceding pregnancy (p = 0.014) and higher BMI (p < 0.001). Higher age was associated with less "trouble sleeping" (OR 0.9, p = 0.033) and longer sleep duration was associated with better "subjective sleep quality" (OR 0.8, p = 0.005). Sleep issues were highly prevalent at baseline and associated with age, irregular menstruation, and obesity. This cohort will provide a robust platform to investigate incident sleep disorders during pregnancy and their effects on adverse pregnancy outcomes and long-term health of women and their offspring.

Obstructive Sleep Apnea Is Associated With Late-Onset Preeclampsia in Overweight Pregnant Women in Korea

BACKGROUND

Obstructive sleep apnea (OSA) is closely related to maternal obesity in pregnant women, and the association increases with later pregnancy. Obesity and OSA are risk factors of pregnancy-related complications, including gestational hypertension, gestational diabetes mellitus (GDM), and fetal morbidities. We aimed to determine the prevalence of OSA and to assess the impact of OSA on pregnancy-related disorders in overweight pregnant women.

METHODS

Eligible participants who were overweight [body mass index (BMI) ≥ 23 kg/m²] in gestational age 30 weeks or more, assessed OSA using a portable polysomnography at home. Clinical data were collected from pregnant women and their babies.

RESULTS

The average age of 51 participants was 34.5 years (27-44 years). The number of primipara was 25 (49%) and that of multipara was 26 (51%). Eight cases of GDM (15.7%) and five cases of preeclampsia (9.8%) were reported, and six patients (11.8%) experienced preterm delivery. In results of polysomnography, 14 patients (27.5%) were diagnosed as OSA. Apnea-hypopnea index moderately correlated with BMI (r = 0.515, P < 0.001). The BMI (P < 0.005) and preeclampsia rate (P < 0.017) were higher in the OSA group compared to the control group. Odds ratios (ORs) adjusting age, BMI, parity, and abortion history were calculated. The presence of OSA increased OR of preeclampsia (OR, 13.1; 95% confidence interval, 1.1-171.3). The majority of preeclampsia patients (4/5, 80%) underwent preterm delivery.

CONCLUSION

OSA is an important risk factor for preeclampsia, resulting in preterm delivery. For overweight pregnant women, an OSA evaluation should be mandatory.

Sleep disordered breathing and the risk of severe maternal morbidity in women with preeclampsia: A population-based study

OBJECTIVE

Obstructive sleep apnea (OSA) may exacerbate the widespread endothelial dysfunction seen in preeclampsia, potentially worsening clinical outcomes. We aimed to assess whether OSA is associated with an increased risk of severe maternal morbidity, cardiovascular morbidity, and healthcare utilization among women with preeclampsia.

STUDY DESIGN

We performed a retrospective cohort study utilizing data from the National Perinatal Information Center (2010-2014) in the United States.The cohort comprised women with preeclampsia. We estimated the association between OSA and the outcomes using logistic regression analyses and determined odds ratio adjusted for demographic factors and comorbidities (ORadj) and associated 95% confidence intervals (CI).

MAIN OUTCOME MEASURES

The primary outcome was a composite of mortality and severe maternal morbidity comprising intensive care unit (ICU) admission, acute renal failure, pulmonary edema, pulmonary embolism, congestive heart failure, cardiomyopathy, and stroke. Secondary outcomes comprised the subset of cardiovascular events, as well as increased healthcare utilization (including Cesarean delivery, preterm birth, ICU admission, and prolonged length of hospital stay).

RESULTS

In total, 71,159 women had preeclampsia, including 270 (0.4 %) with OSA. Women with preeclampsia and OSA were more likely to experience severe maternal morbidity than women without OSA (ORadj 2.65, 95 % CI [1.94-3.61]). Moreover, women with concomitant OSA had more severe cardiovascular morbidity than women without OSA (ORadj 5.05, 95 % CI [2.28-11.17]). Accordingly, OSA was associated with increased healthcare utilization in women with preeclampsia (ORadj. 2.26, 95 % CI [1.45-3.52]).

CONCLUSION

In women with preeclampsia, OSA increases the risk for severe maternal morbidity, cardiovascular morbidity, and healthcare utilization.

A Narrative Review of Sex and Gender Differences in Sleep Disordered Breathing: Gaps and Opportunities

INTRODUCTION

Sleep disordered breathing (SDB) is a common condition, associated with multiple comorbidities including cardiovascular and metabolic disease. It has been previously established that SDB is more prevalent in men than women, shifting the literature's focus away from the latter population. As such, underdiagnosis, and thus undertreatment, of SDB in women exists.

METHODS

To establish the differences in prevalence, clinical presentation, and pathophysiology of SDB between the two sexes, a narrative review of the current literature was performed.

RESULTS

Rates of SDB are higher among men, likely driven by differences in symptom presentation between men and women, with women presenting with more "atypical" symptoms, and lack of sensitivity in SDB screening tools to detect SDB in women. In addition to the cardiovascular risks of SDB, women with SDB may have worse quality of life, higher prevalence of insomnia, and respiratory issues.

DISCUSSION

More research is needed to better define the unique pathophysiology and clinical presentation of SDB in women. In addition, an increased awareness among health care providers and the lay public of the SDB-specific sex and gender differences will serve to minimize disparities in identification and treatment of SDB in women.

Trends in and outcomes associated with obstructive sleep apnea during deliveries in the United States, 2000-2019

BACKGROUND

Population-level data on obstructive sleep apnea among pregnant women in the United States and associated risk for adverse outcomes during delivery may be of clinical importance and public health significance.

OBJECTIVE

This study aimed to assess trends in and outcomes associated with obstructive sleep apnea during delivery hospitalizations.

STUDY DESIGN

This repeated cross-sectional study analyzed delivery hospitalizations using the National Inpatient Sample. Temporal trends in obstructive sleep apnea were analyzed using joinpoint regression to estimate the average annual percentage change with 95% confidence intervals. Survey-adjusted logistic regression models were fit to assess the association between obstructive sleep apnea and mechanical ventilation or tracheostomy, acute respiratory distress syndrome, hypertensive disorders of pregnancy, peripartum hysterectomy, pulmonary edema/heart failure, stillbirth, and preterm birth.

RESULTS

From 2000 to 2019, an estimated 76,753,013 delivery hospitalizations were identified, of which 54,238 (0.07%) had a diagnosis of obstructive sleep apnea. During the study period, the presence of obstructive sleep apnea during delivery hospitalizations increased from 0.4 to 20.5 cases per 10,000 delivery hospitalizations (average annual percentage change, 20.6%; 95% confidence interval, 19.1-22.2). Clinical factors associated with obstructive sleep apnea included obesity (4.3% of women without and 57.7% with obstructive sleep apnea), asthma (3.2% of women without and 25.3% with obstructive sleep apnea), chronic hypertension (2.0% of women without and 24.5% with obstructive sleep apnea), and pregestational diabetes mellitus (0.9% of women without and 10.9% with obstructive sleep apnea). In adjusted analyses accounting for obesity, other clinical factors, demographics, and hospital characteristics, obstructive sleep apnea was associated with increased odds of mechanical ventilation or tracheostomy (adjusted odds ratio, 21.9; 95% confidence interval, 18.0-26.7), acute respiratory distress syndrome (adjusted odds ratio, 5.9; 95% confidence interval, 5.4-6.5), hypertensive disorders of pregnancy (adjusted odds ratio, 1.6; 95% confidence interval, 1.6-1.7), stillbirth (adjusted odds ratio, 1.2; 95% confidence interval, 1.0-1.4), pulmonary edema/heart failure (adjusted odds ratio, 3.7; 95% confidence interval, 2.9-4.7), peripartum hysterectomy (adjusted odds ratio, 1.66; 95% confidence interval, 1.23-2.23), and preterm birth (adjusted odds ratio, 1.2; 95% confidence interval, 1.1-1.2).

CONCLUSION

Obstructive sleep apnea diagnoses are increasingly common in the obstetrical population and are associated with a range of adverse obstetrical outcomes during delivery hospitalizations.

Sex and Gender in Lung Disease and Sleep Disorders: A State-of-the-Art Review

The terms sex and gender often are used interchangeably, but have specific meaning when it comes to their effects on lung disease. Ample evidence is now available that sex and gender affect the incidence, susceptibility, presentation, diagnosis, and severity of many lung diseases. Some conditions are more prevalent in women, such as asthma. Other conditions are seen almost exclusively in women, like lymphangioleiomyomatosis. Some life stages-such as pregnancy-are unique to women and can affect the onset and course of lung disease. Clinical presentation may differ as well, such as higher number of exacerbations experienced by women with COPD and greater cardiovascular morbidity in women with sleep-disordered breathing. In addition, response to therapy and medication safety may also differ by sex, and yet, pharmacogenomic factors often are not addressed adequately in clinical trials. Various aspects of lung and sleep biology and pathobiology are impacted by female sex and female reproductive transitions. Differential gene expression or organ development can be impacted by these biological differences. Understanding these differences is the first step in moving toward precision medicine for women. This article is a state-of-the-art review of specific effects of sex and gender focused on epidemiology, disease presentation, risk factors, and management of lung diseases. Pathobiological mechanisms explaining sex differences in these diseases are beyond the scope of this article. We review the literature and focus on recent guidelines about using sex and gender in research. We also review sex and gender differences in lung diseases.

The association between obstructive sleep apnoea and wound healing: a systematic review

Purpose

Obstructive sleep apnoea (OSA) is a common, significantly underdiagnosed sleep-related breathing disorder, characterised by upper airway collapse and resultant intermittent hypoxia. Oxygen plays an important role in collagen synthesis and as a result in wound healing. An association between OSA and wound healing has not been clearly delineated. A systematic review was performed to understand this association.

Methods

Randomised controlled trials, cohort, cross-sectional and case–control studies evaluating the relationship between OSA or OSA-related symptoms and wound healing in adult populations were searched in the systematic review using electronic databases PubMed, EMBASE and Ovid MEDLINE.

Main results

A total of 11 cohort studies and 1 case–control study with a total of 58,198,463 subjects were included. Most studies suggest that patients diagnosed with OSA or who are at high risk of having OSA are more likely to suffer from wound complications. Patients with OSA have been found to be at higher risk for post-operative wound infection and wound dehiscence. Contradictory results were obtained on time to heal, with one study concluding that individuals with OSA were more likely to heal earlier when compared to patients without OSA. Quality of evidence, however, was deemed very low due to high risk of bias.

Conclusions

This systematic review did identify an association between OSA and wound healing. However, due to the very low-quality evidence, further research is warranted to better characterise this association and investigate whether or not treating OSA can indeed affect wound healing.

Gestational Intermittent Hypoxia Programs Hypertensive Response in Female Rat Offspring: Impact of Ovaries

Obstructive sleep apnea (OSA) is a chronic condition frequently observed in pregnant women. We have shown that gestational intermittent hypoxia (GIH), a hallmark of OSA, leads to sex-specific impairment in the endothelium-dependent relaxation response and an increase in blood pressure in adult male but not female rat offspring. The present study tested the hypothesis that functional ovaries normalize GIH-induced hypertensive response in female offspring. Experiments were done in female offspring of pregnant rats exposed to normoxia or GIH (F_IO2 21-10.5% from gestational days 10 to 21). Ovariectomy and sham surgery were performed at 5 weeks of age. Pups born to GIH dams were significantly smaller than the controls, but they exhibited catch-up growth and were similar to controls by 5 weeks of age. Ovariectomy significantly exacerbated bodyweight gain to a similar extent in both control and GIH offspring. Marked increases in blood pressure were observed in pre-pubertal GIH offspring compared to controls; however, after puberty, blood pressure in GIH offspring progressively decreased and became normotensive at adulthood. Ovariectomy led to the maintenance of higher blood pressure in post-pubertal GIH offspring with no significant effect in controls. Vascular contractile and relaxation responses were not affected in the GIH and control offspring; however, ovariectomy selectively decreased endothelium-dependent relaxation response along with a decrease in endothelial nitric oxide synthase expression in the GIH offspring. These findings suggest that functional ovaries are crucial in protecting females against GIH-mediated endothelial dysfunction and hypertension in adulthood.

Development and Internal Validation of a Risk Prediction Model for Acute Cardiovascular Morbidity in Preeclampsia

BACKGROUND

Persons with preeclampsia are at increased short-term risk of adverse cardiovascular outcomes during pregnancy and the early postpartum period. We aimed to develop and internally validate a risk assessment tool to predict acute cardiovascular morbidity in preeclampsia.

METHODS

The study was conducted at an academic obstetric hospital. Participants with preeclampsia at delivery between 2007 and 2017 were included. A model to predict acute cardiovascular morbidity at delivery and within 6 weeks postpartum was developed and evaluated. The primary composite outcome included pulmonary edema/acute heart failure, myocardial infarction, aneurysm, cardiac arrest/ventricular fibrillation, heart failure/arrest during surgery or procedure, cerebrovascular disorders, cardiogenic shock, conversion of cardiac rhythm, and difficult-to-control severe hypertension. We assessed model discrimination and calibration. We used bootstrapping for internal validation.

RESULTS

4,171 participants with preeclampsia were included. The final model comprised 8 variables. Predictors positively associated with acute cardiovascular morbidity (presented as odds ratio [OR] with 95% confidence interval [CI]) were: gestational age at delivery (20-36 weeks 5.36 [3.67, 7.82]; 37-38 weeks 1.75 [1.16, 2.64]), maternal age (≥40 years 1.65 [1.00, 2.72]; 35-39 years 1.49 [1.07, 2.09]), and prior cesarean delivery (1.47, [1.01, 2.13]). The model had an area under the receiver operating characteristic curve of 0.72 (95% CI [0.69, 0.74]). Moreover, it was adequately calibrated and performed well on internal validation.

CONCLUSIONS

This risk prediction tool identified women with preeclampsia at highest risk of acute cardiovascular morbidity. If externally validated, this tool may facilitate early interventions aimed at preventing adverse cardiovascular outcomes in pregnancy and postpartum.

Association between sleep disordered breathing in early pregnancy and glucose metabolism

STUDY OBJECTIVES

To examine the association between maternal sleep disordered breathing (SDB) and glucose metabolism in early gestation.

METHODS

Women with body mass index (BMI) ≥27 kg/m2 and singleton pregnancies underwent in-home sleep study (HSAT) and homeostatic model assessment (HOMA) in early pregnancy. Insulin resistance (HOMA-IR) and β-cell function (HOMA %B) were derived. Exclusion criteria included pregestational diabetes, use of continuous positive airway pressure and chronic steroid therapy. We performed linear regression analyses to evaluate the association between continuous measures of SDB (respiratory event index (REI), and oxygen desaturation index (ODI)) and glucose metabolism parameters (HOMA-IR and HOMA %B). Analyses were adjusted for a set of a priori selected variables which included gestational age, maternal age, BMI, ethnicity, race, and parity.

RESULTS

One hundred and ninety-two pregnant women with median (interquartile range) BMI of 35.14 (8.30) kg/m2 underwent HSAT and HOMA assessment at 11.14 (3) and 15.35 (4.14) gestational weeks, respectively. REI and ODI, as continuous values, were associated with HOMA-IR after adjusting for covariates. OSA (obstructive sleep apnea) diagnosis (REI > 5 events per hour) was not associated with HOMA-IR after adjusting for BMI (p ≥ 0.05). None of the parameters were associated with HOMA %B (p > 0.07).

CONCLUSIONS

SDB and insulin resistance are associated in early pregnancy, with a dose response association between respiratory event index severity and insulin resistance. Further studies are needed to establish if pregnant women with overweight and obesity may benefit from early SDB screening to improve glucose metabolic outcome. Clinical trials: NCT02412696, Positive Airway Pressure, Sleep Apnea, and the Placenta (PAP-SAP) https://clinicaltrials.gov/ct2/show/NCT02412696?term=Bourjeily&draw=2&rank=2 and NCT02917876, Predictors of De-novo Development of Obstructive Sleep Apnea in Pregnancy (Predictors) https://clinicaltrials.gov/ct2/show/NCT02917876?term=Bourjeily&draw=2&rank=1.

Obstructive sleep apnea in pregnant women

The prevalence of OSA in the low-risk obstetric population is thought to be low; best estimates have been extrapolated from the one available large prospective study and likely range between 3–8%.1 OSA prevalence in high-risk pregnant women such as those with obesity and chronic hypertension is significantly higher as extrapolated from several smaller prospective studies which have reported a prevalence as high as 37% in obese women.2 –6 Despite the high prevalence of OSA in high-risk pregnant women, it remains underdiagnosed due to several factors.

An emerging body of literature suggests that OSA may also have serious implications for the health of mothers and fetuses during and beyond pregnancy, but there is still no data to determine if OSA treatment mitigates these adverse outcomes. In this review, we will examine this body of literature from the perspective of the anesthesiologist: the association between pregnancy and the development or worsening of OSA; OSA as it relates to adverse maternal and fetal outcomes; antepartum and screening considerations for OSA in pregnant women; and recommendations regarding the peripartum management of OSA.

A Review of the Associations Between Obstructive Sleep Apnea and Gestational Diabetes Mellitus and Possible Mechanisms of Disease

Obstructive sleep apnea (OSA) usually leads to the occurrence of diabetes. Gestational diabetes mellitus (GDM) is a common gestational complication associated with adverse maternal and fetal outcomes. Increasing studies suggest that women with OSA during pregnancy may be at a significantly greater risk of developing GDM. It is crucial to explore the association between OSA and GDM and the mechanisms underlying this association. In this review, we presented a comprehensive literature review of the following: the association between OSA and GDM, the possible mechanisms of this association, and the effects of continuous positive airway pressure (CPAP) on OSA with GDM. The results showed that most authors suggested that there was an association between OSA and GDM. The intermittent hypoxemia (IH) and reduction of slow-wave sleep (SWS) may be the key to this association. IH induces the products of oxidative stress and inflammation as well as dysregulation of the hypothalamic-pituitary-adrenal, which lead to diabetes. In addition, SWS reduction in OSA enhances the inflammation by increasing the inflammatory cytokines, increases the sympathetic activation, and causes changes in leptin level, which result in the development of GDM. Additionally, whether CPAP is beneficial to GDM remains still unclear.

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.

A feature of maternal sleep apnea during gestation causes autism-relevant neuronal and behavioral phenotypes in offspring

Mounting epidemiologic and scientific evidence indicates that many psychiatric disorders originate from a complex interplay between genetics and early life experiences, particularly in the womb. Despite decades of research, our understanding of the precise prenatal and perinatal experiences that increase susceptibility to neurodevelopmental disorders remains incomplete. Sleep apnea (SA) is increasingly common during pregnancy and is characterized by recurrent partial or complete cessations in breathing during sleep. SA causes pathological drops in blood oxygen levels (intermittent hypoxia, IH), often hundreds of times each night. Although SA is known to cause adverse pregnancy and neonatal outcomes, the long-term consequences of maternal SA during pregnancy on brain-based behavioral outcomes and associated neuronal functioning in the offspring remain unknown. We developed a rat model of maternal SA during pregnancy by exposing dams to IH, a hallmark feature of SA, during gestational days 10 to 21 and investigated the consequences on the offspring's forebrain synaptic structure, synaptic function, and behavioral phenotypes across multiples stages of development. Our findings represent a rare example of prenatal factors causing sexually dimorphic behavioral phenotypes associated with excessive (rather than reduced) synapse numbers and implicate hyperactivity of the mammalian target of rapamycin (mTOR) pathway in contributing to the behavioral aberrations. These findings have implications for neuropsychiatric disorders typified by superfluous synapse maintenance that are believed to result, at least in part, from largely unknown insults to the maternal environment.

Impact of sleep patterns upon female neuroendocrinology and reproductive outcomes: a comprehensive review

Sleep is vital to human bodily function. Growing evidence indicates that sleep deprivation, disruption, dysrhythmia, and disorders are associated with impaired reproductive function and poor clinical outcomes in women. These associations are largely mediated by molecular-genetic and hormonal pathways, which are crucial for the complex and time sensitive processes of hormone synthesis/secretion, folliculogenesis, ovulation, fertilization, implantation, and menstruation. Pathologic sleep patterns are closely linked to menstrual irregularity, polycystic ovarian syndrome, premature ovarian insufficiency, sub/infertility, and early pregnancy loss. Measures of success with assisted reproductive technology are also lower among women who engage in shift work, or experience sleep disruption or short sleep duration. Extremes of sleep duration, poor sleep quality, sleep disordered breathing, and shift work are also associated with several harmful conditions in pregnancy, including gestational diabetes and hypertensive disorders. While accumulating evidence implicates pathologic sleep patterns in impaired reproductive function and poor reproductive outcomes, additional research is needed to determine causality and propose therapeutic interventions.

The cardiovascular, metabolic, fetal and neonatal effects of CPAP use in pregnant women: a systematic review

Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea (OSA), but its outcomes for the pregnant are still undefined. This study aims to review current CPAP intervention during pregnancy, discuss published trials, and propose relevant issues that have yet to be addressed satisfactorily about the cardiovascular, metabolic, fetal, and neonatal effects of CPAP treatment during gestation. Two authors independently conducted a systematic review until March 28th, 2021 on PubMed, BVS, and Cochrane Library, using PRISMA guidelines, and risk of bias. Discrepancies were reconciled by a third reviewer. Of 59 identified citations, eight original trials have submitted a total of 90 pregnant women to polysomnography and CPAP therapy. Four studies performed in samples with hypertension or preeclampsia presented blood pressure decrease or maintained the antihypertensive drug dose in the CPAP group. After CPAP utilization, one trial registered cardiac output and stroke volume increase with heart rate and peripheral vascular resistance decrease, which were correlated with birth weight increment. Others documented a higher Apgar in the CPAP group and more fetal movements during CPAP use. There was a reduction in serum uric acid and tumor necrosis factor-alpha in the CPAP groups whose blood pressure decreased. However, two weeks of CPAP use in women with gestational diabetes and OSA did not improve glucose levels but raised the insulin secretion in those adherents to CPAP. Despite these positive results without adverse effects, randomized controlled trials with standardized follow-up in larger populations are required to determine CPAP therapy recommendations in pregnancy.

Maternal habitual snoring and blood pressure trajectories in pregnancy

STUDY OBJECTIVES

Habitual snoring has been associated with hypertensive disorders of pregnancy. However, exactly when blood pressure (BP) trajectories diverge between pregnant women with and without habitual snoring is unknown. Moreover, the potentially differential impact of chronic vs pregnancy-onset habitual snoring on maternal BP trajectories during pregnancy has not been examined. This study compared patterns of BP across pregnancy in 3 groups of women: those with chronic habitual snoring, those with pregnancy-onset habitual snoring, and nonhabitual snoring "controls."

METHODS

In a cohort study of 1,305 pregnant women from a large medical center, participants were asked about habitual snoring (≥ 3 nights/week) and whether their symptoms began prior to or during pregnancy. Demographic, health, and BP data throughout pregnancy were abstracted from medical charts. Linear mixed models were used to examine associations between habitual snoring-onset and pregnancy BP trajectories.

RESULTS

A third of women reported snoring prior to pregnancy (chronic snoring) and an additional 23% reported pregnancy-onset snoring. Mean maternal age (SD) was 29.5 (5.6), 30 (6), and 30.5 (5.7) years in controls, chronic, and pregnancy-onset snoring, respectively. Overall, women with pregnancy-onset snoring had higher mean systolic BP and diastolic BP compared to those with chronic habitual snoring or nonhabitual snoring. In gestational week-specific comparisons with controls, systolic BP became significantly higher around 18 weeks' gestation among women with pregnancy-onset snoring and in the third trimester among women with chronic snoring. These differences became detectable at 1 mm Hg and increased thereafter, reaching 3 mm Hg-BP difference at 40 weeks' gestation in women with pregnancy-onset snoring relative to controls. Pairwise mean differences in diastolic BP were significant only among women with pregnancy-onset snoring relative to controls, after 15 weeks' gestation.

CONCLUSIONS

Pregnancy-onset and chronic maternal snoring are associated with higher BPs beginning in the second and third trimester, respectively. Pregnancy BP trajectories could identify critical windows for enhanced BP surveillance; the divergent BP trajectories suggest that the 2 groups of women with habitual snoring in pregnancy may need to be considered separately when gestational time intervals are evaluated for increased BP monitoring.

CITATION

Dunietz GL, Hao W, Shedden K, et al. Maternal habitual snoring and blood pressure trajectories in pregnancy. J Clin Sleep Med. 2022;18(1):31-38.

Maternal and fetal outcomes in pregnancies with obstructive sleep apnea

OBJECTIVES

Obstructive sleep apnea (OSA) is linked to many health comorbidities. We aimed to ascertain if OSA correlates with a rise in poor obstetrical outcomes.

METHODS

Employing the United States' Healthcare Cost and Utilization Project - National Inpatient Sample, we performed our retrospective cohort study including all women who delivered between 2006 and 2015. ICD-9 codes were used to characterize women as having a diagnosis of OSA. Temporal trends in pregnancies with OSA were studied, baseline features were evaluated among gravidities in the presence and absence of OSA, and multivariate logistic regression analysis was utilized in assessing consequences of OSA on patient and newborn outcomes.

RESULTS

Of a total 7,907,139 deliveries, 3,115 belonged to patients suffering from OSA, resulting in a prevalence of 39 per 100,000 deliveries. Rates rose from 10.14 to 78.12 per 100,000 deliveries during the study interval (p<0.0001). Patients diagnosed with OSA were at higher risk of having pregnancies with preeclampsia, OR 2.2 (95% CI 2.0-2.4), eclampsia, 4.1 (2.4-7.0), chorioamnionitis, 1.4 (1.2-1.8), postpartum hemorrhage, 1.4 (1.2-1.7), venous thromboembolisms, 2.7 (2.1-3.4), and to deliver by caesarean section, 2.1 (1.9-2.3). Cardiovascular and respiratory complications were also more common among these women, as was maternal death, 4.2 (2.2-8.0). Newborns of OSA patients were at elevated risk of being premature, 1.3 (1.2-1.5) and having congenital abnormalities, 2.3 (1.7-3.0).

CONCLUSIONS

Pregnancies with OSA were linked to an elevated risk of poor maternal and neonatal outcomes. During pregnancy, OSA patients should receive attentive follow-up care in a tertiary hospital.

Postpartum Respiratory Depression

Postpartum respiratory depression is a complex, multifactorial issue that encompasses a patient's baseline preexisting conditions, certain pregnancy-specific conditions or complications, as well as the iatrogenic element of various medications given in the peripartum period. In this review, we discuss many of these factors including obesity, sleep-disordered breathing, chronic lung disease, neuromuscular disorders, opioids, preeclampsia, peripartum cardiomyopathy, postpartum hemorrhage, amniotic fluid embolism, sepsis, acute respiratory distress syndrome (ARDS), and medications such as analgesics, sedatives, anesthetics, and magnesium. Current recommendations for screening, treatment, and prevention are also discussed.