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

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.

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.

The Prevalence of Restless Legs Syndrome Among Pregnant Women in Saudi Arabia

INTRODUCTION

Pregnancy has been associated with restless legs syndrome (RLS). RLS is underdiagnosed in most countries. The purpose of this study was to assess the prevalence of RLS among Saudi pregnant women.

METHODS

This cross-sectional study included 459 pregnant women from all Saudi provinces between December 2022 and March 2023. A structured online questionnaire assessing demographic and pregnancy characteristics, medical conditions, sleep quality, and RLS symptoms was conducted.

RESULTS

The prevalence of RLS was 26.6% among the participants. Calcium deficiency was significantly associated with RLS (adjusted odds ratio (OR)=2.16, 95% confidence interval (CI)=1.2-3.9, p=0.01), but there was no significant association between RLS and vitamin D and iron deficiencies (p>0.05), according to multivariate binary logistic regression analysis. Moreover, RLS increased the risk of insomnia and frequent waking up (adjusted OR=4.95, 95% CI=2.50-9.83, p<0.001, and adjusted OR=2.87, 95% CI=1.55-5.32, p=0.001, respectively).

CONCLUSION

RLS is common among pregnant women in Saudi Arabia. The study indicates that RLS during pregnancy is linked to calcium deficiency and negatively affects sleep quality.

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.

Effects of Compound Danshen Injection Combined with Magnesium Sulfate on Pregnancy-Induced Hypertension Syndrome under the Guidance of Empirical Mode Decomposition Algorithm-Based Ultrasound Image

Objective

The study focused on the separation effects of ultrasound blood flow signal detection, based on empirical mode decomposition (EMD) algorithm, and the clinical efficacy of Compound Danshen injection and magnesium sulfate in the treatment of pregnancy-induced hypertension (PIH) syndrome.

Methods

The empirical mode decomposition (EMD) algorithm was optimized first and compared with other algorithms for the accuracy and stability in separation of blood flow signals. 80 patients with PIH syndrome undergoing ultrasound examination were selected as the research subjects and randomly divided into control group and observation group according to the actual treatment methods. 40 cases in the observation group were treated with Compound Danshen injection + magnesium sulfate, and 40 cases in the control group were treated with magnesium sulfate. After the treatment, the clinical indicators of the two groups of patients were analyzed.

Results

The accuracy and stability in separating blood flow signal of the optimized EMD algorithm were better than those of other algorithms. After treatment, the total effective rate and blood pressure control of the observation group were significantly better than those of the control group, and the incidence of adverse maternal and infant outcomes was significantly lower than that of the control group. After treatment, the endothelin-1 (ET-1), C-reactive protein (CRP), and homocysteine (Hcy) indexes of the two groups of patients decreased significantly, and the decrease level of the observation group was significantly greater than that of the control group (P < 0.05). The prothrombin time (PT), fibrinogen (FIB), activated partial thromboplastin time (APTT), and plasma thrombin time (TT) levels of the two groups after treatment were better than those before treatment, and the observation group was better than the control group (P < 0.05).

Conclusion

The optimized EMD algorithm is of great value for the separation of ultrasound blood flow signals. For patients with PIH syndrome, Compound Danshen injection combined with magnesium sulfate can be used as a treatment plan, which can improve maternal and infant outcomes; control blood pressure; reduce 24 h urine protein and serum ET-1, Hcy, and CRP levels; and improve coagulation function. It is worthy of promotion.

Role of miR-106-mediated mitogen-activated protein kinase signaling pathway in oxidative stress injury and inflammatory infiltration in the liver of the mouse with gestational hypertension

We aim to investigate the role of miR-106-mediated mitogen-activated protein kinase (MAPK) signaling pathway in oxidative stress (OS) injury and inflammatory infiltration in the liver of the mouse with gestational hypertension (GH). Ninety specific pathogen-free mice (Kunming species) during middle to late gestation were selected for the study. Fifteen mice were used as control, while the rest were used for establishing the GH model. The mice were assigned to six groups: normal group (normal gestation), model group (GH model), negative control group (GH model, intravenously injected with negative control vector), miR-106a-mimic group (GH model, intravenously injected with vector overexpressing miR-106a, which mimics the overexpression of endogenous mature miR-106a), SB203580 group (GH model, intravenously injected with MAPK pathway inhibitor SB203580), and miR-106a-mimic+SB203580 group (GH model, intravenously injected with SB203580 and vector overexpressing miR-106a). Fourteen days after electrical stimulation, all the groups except for the normal group had elevated blood pressure vs those on day 0 and 7. Compared with the normal group, the other groups had lower levels of miR-106a expression, nitric oxide, nitric oxide synthase, catalase, superoxide dismutase, S cell ratio, and interleukin-4 (IL-4) and IL-10 in the serum and liver as opposed to increased levels of blood pressure, p38MAPK mRNA expression, p-p38MAPK positive expression rate, protein expressions of p-p38MAPK, p-ERK, and p-JNK, H₂ O₂ and malondialdehyde in liver, G0/G1 cell ratio, apoptosis rate, and IL-6, interferon-γ (IFN-γ), and IFN-α in the serum and liver (all P < .05). The miR-106 overexpression or inhibiting MAPK signaling pathway can attenuate OS injury and inflammatory response in the liver of the mouse with GH, and the effect can be even better if both miR-106a overexpression and inhibiting MAPK pathway are applied. In conclusion, miR-106a overexpression can inhibit OS injury and inflammatory infiltration in the liver of the mouse with GH by mediating MAPK signaling pathway.

New-onset restless leg syndrome in a COVID-19 patient: a case report with literature review

Restless leg syndrome (RLS) is a sleep disorder characterized by the sudden urge to move the lower limbs during periods of rest accompanied by an unpleasant sensation like tingling or burning in the legs. Often, this urge is partially relieved by the movement of legs. However, it causes disturbance of sleep leading to daytime fatigue. Herein, we present an unusual case of new-onset of restless leg syndrome in a COVID-19 infected patient who presented three weeks after an uncomplicated delivery via caesarean section. The patient was managed with sleep hygiene measures, oral iron and vitamin C tablets apart from general COVID-19 management medications, subsequently leading to significant improvements. Here we have discussed possible associated factors, pathophysiological mechanisms and management of RLS in the case of COVID infected individuals.

Is there a relationship between restless legs syndrome and medical problems in pregnant women? A cross-sectional study in Iran

This study aimed to assess the relationship between RLS and medical problems among pregnant women. In this study, 700 pregnant women were recruited. A socio-demographic questionnaire and the International Restless Legs Questionnaire were used to gather information. Data analyzed using an independent t test, Chi-square, and multivariate analysis. The prevalence of RLS was 28.9%. Women with hypertension were 1.90 times more probable to have RLS (adjusted OR 1.90, CI 1.14-3.19). Women with chronic hypertension and superimposed preeclampsia were 2.39 and 2.13 times more probable to experience RLS, respectively. Pre-eclamptic women were 1.87 times more probable to experience RLS. Women with diabetes, gestational diabetes and anemia have also been more likely to have RLS. Results of the present study show that there is a significant relationship between RLS and medical problems such as chronic hypertension, superimposed preeclampsia, gestational diabetes and anemia among pregnant women.

Restless Legs Syndrome and Severe Preeclampsia: A Case-Control Study

OBJECTIVE

This study sought to determine whether there is an association between restless legs syndrome (RLS) and severe preeclampsia using a case-control study design.

METHODS

A total of 147 patients with severe preeclampsia and 147 patients with normal pregnancies were evaluated for symptoms of RLS. In the first phase, before or immediately after delivery, participants were given a questionnaire on common complaints experienced during pregnancy. Mixed with these complaints were the symptoms that comprised the diagnostic criteria for RLS. If a participant indicated she met the diagnositic criteria, she was informed about RLS. In the second phase, a severity evaluation was performed in this population using the International Restless Legs Syndrome Study Group Rating Scale.

RESULTS

Among the participants, independent of the presence of preeclampsia, 13.61% met the criteria for a diagnosis of RLS. There was no statistical difference between groups (severe preeclampsia: 12.93% vs. controls: 14.29%; odds ratio [OR] 0.89; 95% CI 0.46-1.74, P = 0.37). After analysis, 65% of patients with RLS had a score on the International Restless Legs Syndrome Study Group Rating Scale compatible with "very severe" or "severe" RLS. There was again no statistical difference between groups for the combination of "severe" and "very severe" scoring criteria (severe preeclampsia: 68.42% vs. controls: 61.90%; OR 1.33; 95% CI 0.36-4.93, P = 0.66) and "very severe" alone (severe preeclampsia: 21.05% vs. controls: 4.76%; OR 5.33; 95% CI 0.54-52.73, P = 0.11).

CONCLUSION

The prevalence of RLS among pregnant women in our study was in accordance with the medical literature and avoided the probable bias caused by the high number of other symptoms experienced during pregnancy. There were no significant differences between normotensive participants and those with severe preeclampsia. In general, symptom severity was high, with a tendency toward greater severity in patients with severe preeclampsia, but this difference did not reach statistical significance.

Why Are Women Prone to Restless Legs Syndrome?

Restless legs syndrome is a relatively common neurologic disorder considerably more prevalent in women than in men. It is characterized by an inactivity-induced, mostly nocturnal, uncomfortable sensation in the legs and an urge to move them to make the disagreeable sensation disappear. Some known genes contribute to this disorder and the same genes contribute to an overlapping condition—periodic leg movements that occur during sleep and result in insomnia. Dopamine and glutamate transmission in the central nervous system are involved in the pathophysiology, and an iron deficiency has been shown in region-specific areas of the brain. A review of the literature shows that pregnant women are at particular risk and that increased parity is a predisposing factor. Paradoxically, menopause increases the prevalence and severity of symptoms. This implies a complex role for reproductive hormones. It suggests that changes rather than absolute levels of estrogen may be responsible for the initiation of symptoms. Both iron (at relatively low levels in women) and estrogen (at relatively high oscillating levels in women) influence dopamine and glutamate transmission, which may help to explain women’s vulnerability to this condition. The syndrome is comorbid with several disorders (such as migraine, depression, and anxiety) to which women are particularly prone. This implies that the comorbid condition or its treatment, or both, contribute to the much higher prevalence in women than in men of restless legs syndrome.

The association between obesity and restless legs syndrome: A systemic review and meta-analysis of observational studies

OBJECTIVE

Restless legs syndrome (RLS) has been reported to occur more frequently in obese individuals than in those with normal weight. In this study, a systematic review and meta-analysis was performed to explore the relationship between obesity and RLS.

METHODS

Published articles were identified through a comprehensive review of PUBMED and EMBASE from inception to the 16th December 2017. Data from studies reporting relative risks, odds ratios, or hazard ratios comparing the risk of RLS among individuals with obesity versus people with normal weight were analyzed. A random-effect model was used to calculate pooled odds ratios and 95% confident intervals (CI) for the association between obesity and RLS.

RESULTS

Findings for a total of 197,204 participants were pooled across 15 studies and were examined. Our analyses demonstrated a positive association between obesity and RLS, with an odds ratio (OR) of 1.44 (95%CI: 1.31-1.58, I² = 62.3%). Overweight subjects were also likely to have RLS, with an odds ratio of 1.29 (95%CI: 1.22-1.36, I² = 0). In subgroup analysis, women (OR = 1.42) with obesity were more likely to have RLS as compared with men (OR = 1.19).

CONCLUSIONS

Adults with obesity are more likely to suffer from RLS, with women at higher risk.

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.

Managing Sleep Disorders during Pregnancy

Sleep disturbances and disorders are common during pregnancy, and they can be risk factors for a number of serious pregnancy-related sleep disorders. These include postpartum depression, pregnancy-induced hypertension, gestational diabetes, and intrauterine growth retardation. In addition, certain chronic sleep disorders, such as narcolepsy, are quite challenging to manage in the context of pregnancy and during lactation, particularly with medications that can be teratogenic. This review discusses 4 common sleep disorders and their impacts on pregnancy, and suggests ways to deal with these disorders that improves maternal and fetal outcomes safely. The review discusses diagnosis and treatment of obstructive sleep apnea, restless legs syndrome, insomnia, and narcolepsy in pregnancy.