Narcolepsy and pregnancy: a retrospective European evaluation of 249 pregnancies

Sleep disorders during pregnancy: an underestimated risk factor for gestational diabetes mellitus

Sleep disorders are highly prevalent during pregnancy and significantly affect women's health and quality of life. Gestational diabetes mellitus (GDM) is one of the most common metabolic complications during pregnancy and constitutes a significant risk factor for both mother and fetus in the short and the long term. While the association between sleep disorders and type 2 diabetes mellitus (T2DM) is indisputable, it is not clear whether there is a link between sleep disorders and GDM. The aim of this article was to investigate the association between sleep disorders and GDM and whether the treatment of sleep disorders may prevent GDM development. Insomnia, obstructive sleep apnea (OSA), restless legs syndrome (RLS), and narcolepsy were the most common sleep disorders identified during pregnancy and were related to poor sleep quality and short or prolonged sleep duration. They were all associated with an increased risk of GDM. The ideal sleep duration for pregnant women was determined at 8-9 h daily. In conclusion, sleep disorders constitute a risk factor for GDM. It is imperative that prospective studies be conducted to evaluate the effect of the early management of sleep disorders on GDM manifestation and control. Healthcare providers should highlight the importance of sufficient sleep to reinforce pregnancy outcomes.

[Potential teratogenicity of modafinil - Conflicting evidence, need for research]

Central disorders of hypersomnolence include narcolepsy type 1, narcolepsy type 2, idiopathic hypersomnia and hypersomnia associated with medical or mental disorders. Treatment is both non-pharmacological and pharmacological, including wake enhancing drugs and stimulants. One of the first-line treatment (modafinil, MODIODAL®) was the subject of a health authority alert in 2019 concerning a risk of major congenital malformations when taken during organogenesis. Since this date, three epidemiological studies have presented contradictory results. Given their methodological weaknesses, it is not possible at this stage to confirm or deny such a risk for the embryo and its nature if there is one. In clinical practice, because of these uncertainties, it is preferable if possible to suspend the treatment of a pregnant woman during the first 10 weeks from last menstrual period (organogenesis). There is an unmet clinical need for research to clarify the potential teratogenic impact of modafinil.

Pharmacologic Treatment of Sleep Disorders in Pregnancy

Pregnancy is a unique physiologic state whose characteristics often predispose women to new-onset sleep disturbances or exacerbations of preexisting sleep disorders. Pregnancy-related factors that can disrupt sleep include heartburn, nocturnal oxytocin secretion, nocturia, and fetal movement. Sleep disorders in pregnancy include insomnia (primary and secondary), restless legs syndrome, and narcolepsy.

Sleep disorders in pregnancy

Sleep disturbances are common in pregnancy and affect sleep quality. The maternal body is going through constant physical and physiological changes to adapt to the growing fetus. Sleep disorders may manifest at any point during pregnancy; some may result in adverse maternal or fetal outcomes. A strong clinical suspicion is crucial to identify sleep disorders in pregnancy and their management should be evaluated with a multidisciplinary team approach. In this review, we provide an overview of changes in sleep during pregnancy and summarise the key features of common sleep disorders in pregnancy, including practical tips on their management.

Educational aims

To provide an overview of common sleep disorders in pregnancy and their management options.

To highlight the impact of the physiological changes in pregnancy on sleep.

To outline the type of sleep studies available to investigate sleep disorders in pregnancy.

Successful lactation after resuming methylphenidate in a woman with narcolepsy

BACKGROUND

New mothers with narcolepsy face difficult decisions about medications and breastfeeding in addition to the more typical challenges of becoming a parent. Scant data are available to guide these choices.

CASE

A 30-year-old G1P1 woman with narcolepsy with cataplexy fed her infant breastmilk for 7 months by exclusive pumping. She chose to discontinue her stimulants at delivery, and restarted methylphenidate when her infant was 13 weeks old. The woman tracked milk production on an app geared towards new parents. Average daily volume was 751±228 ml before and 822±177 ml after restarting methylphenidate. Her infant's growth was appropriate and did not decrease after resuming medications.

CONCLUSIONS

In this new mother with narcolepsy, resuming methylphenidate did not reduce breastmilk volumes or negatively impact her infant. Tracking apps and other technologies can increase patients' confidence and provide data to address gaps in medical knowledge.

Pregnancy and Fetal Outcomes Following Exposure to Modafinil and Armodafinil During Pregnancy

This cohort study uses data from the US Provigil/Nuvigil Pregnancy Registry to assess prevalence of fetal major congenital malformations after exposure to modafinil and armodafinil during pregnancy.

Associations of plasma hypocretin-1 with metabolic and reproductive health: Two systematic reviews of clinical studies

The hypocretin system consists of two peptides hypocretin-1 and hypocretin-2 (HCRT1 and HCRT2). Hypocretin-containing neurons are located in the posterior and lateral hypothalamus, and have widespread projections throughout the brain and spinal cord. In addition to its presence in the cerebrospinal fluid (CSF), peripheral HCRT1 has been detected in plasma. Robust experimental evidence demonstrates functions of hypothalamic-originated HCRT1 in regulation of multiple biological systems related to sleep-wake states, energy homeostasis and endocrine function. In contrast, HCRT1 studies with human participants are limited by the necessarily invasive assessment of CSF HCRT1 to patients with underlying morbidity. Regulation by HCRT1 of energy homeostasis and reproduction in animals suggests similar regulation in humans and prompts these two systematic reviews. These reviews translate prior experimental findings from animal studies to humans and examine associations between HCRT1 and: 1) metabolic risk factors; 2) reproductive function in men, women and children. A total of 21 studies and six studies met the inclusion criteria for the two searches, respectively. Research question, study design, study population, assessments of HCRT1, reproductive, cardiometabolic data and main findings were extracted. Associations between HCRT1, metabolic and reproductive function are inconsistent. Limitations of studies and future research directions are outlined.

Living with Narcolepsy: Current Management Strategies, Future Prospects, and Overlooked Real-Life Concerns

Narcolepsy is a neurological disorder of the sleep-wake cycle characterized by excessive daytime sleepiness (EDS), cataplexy, nighttime sleep disturbances, and REM-sleep-related phenomena (sleep paralysis, hallucinations) that intrude into wakefulness. Dysfunction of the hypocretin/orexin system has been implicated as the underlying cause of narcolepsy with cataplexy. In most people with narcolepsy, symptom onset occurs between the ages of 10 and 35 years, but because the disorder is underrecognized and testing is complex, delays in diagnosis and treatment are common. Narcolepsy is treated with a combination of lifestyle modifications and medications that promote wakefulness and suppress cataplexy. Treatments are often effective in improving daytime functioning for individuals with narcolepsy, but side effects and/or lack of efficacy can result in suboptimal management of symptoms and, in many cases, significant residual impairment. Additionally, the psychosocial ramifications of narcolepsy are often neglected. Recently two new pharmacologic treatment options, solriamfetol and pitolisant, have been approved for adults, and the indication for sodium oxybate in narcolepsy has been expanded to include children. In recent years, there has been an uptick in patient-centered research, and promising new diagnostic and therapeutic options are in development. This paper summarizes current and prospective pharmacological therapies for treating both EDS and cataplexy, discusses concerns specific to children and reproductive-age women with narcolepsy, and reviews the negative impact of health-related stigma and efforts to address narcolepsy stigma.

Three Decades of Progress in Sleep Disorders and Sleep Health for Women

Over the past 3 decades, significant strides have been made in the field of sleep medicine for women. The impact of sex and gender on sleep health and sleep disorders received little attention in the early 1990s, but driven by policies ensuring inclusion of women in medical research, more recent studies have identified sex differences in sleep and investigated gender differences in sleep disorders. Nevertheless, disparities remain: diagnosis of sleep disorders, such as obstructive sleep apnea, narcolepsy, and rapid eye movement (REM) sleep behavior disorder are often delayed and underdiagnosed in women. Future research should continue to examine how biological sex and identity across the gender spectrum influence sleep health and sleep disorders, allowing for more personalized health care for all patients.

The influence of orexin B on the transcriptome profile of porcine myometrial explants during early implantation

This study aimed to determine the effect of orexin B (OXB) on the global expression pattern and the relationships among differentially expressed genes (DE-genes) in the transcriptome of myometrial explants during the early implantation period in the pig (day 15 of pregnancy). The changes in the transcriptome profile of the porcine myometrium were investigated using the Porcine (V2) Two-colour Gene Expression Microarray, 4 × 44. An analysis of the data from the microarray experiment revealed that 1540 DE-genes were affected by OXB, of which 1135 exhibited fold changes (FC) greater than 1.2 (P < 0.05). Among these, 576 genes were up-regulated and 559 genes were down-regulated. Among the affected biological processes in the myometrial tissue, 76 were enhanced and 31 were suppressed. Furthermore, the differential expression of nine genes, related to the regulation of reproductive functions and metabolic homeostasis, was confirmed by quantitative RT-PCR. A functional analysis of the relationships between DE-genes indicated that OXB interacts with the genes involved in the processes such as the inflammatory response, the response to interleukin-6, cytokine receptor activity, the regulation of cell activation, growth factor receptor binding, lipid modification and the steroid metabolic process. An analysis of DE-genes and their functional relationships suggests that OXB could be involved in the mechanisms such as the regulation of cell proliferation and development, inhibition of contractility, regulation of programmed cell death, and the development of blood vessels, all of which facilitate implantation.

Giving a voice to cataplectic experience: recollections from patients with narcolepsy type 1

STUDY OBJECTIVES

The objective of this study was to assess the narratives from the recalled accounts of cataplexy attacks of patients with narcolepsy type 1 (NT1).

METHODS

Twenty-two drug-naive adult patients meeting the International Classification of Sleep Disorders criteria for the diagnosis of NT1 referring to the Narcolepsy Center of the University of Bologna in the year 2017 underwent a semistructured interview focusing on their personal experiences during the cataplectic attacks. Verbatim transcripts were analyzed by thematic analysis of elementary contexts using T-LAB software.

RESULTS

The thematic analysis performed on the entire body text showed 3 clusters that explained 36.2%, 34.1%, and 29.7% of the variance, respectively: a cluster related to situations that trigger attacks of cataplexy, a cluster to bodily sensations, and another control strategies during episodes. The thematic content highlighted a tendency to disregard emotional experiences, thus affecting the ability to name, recognize, and regulate critical emotions.

CONCLUSIONS

The study showed that patients with NT1 spoke of their cataplectic attacks in terms of self-reported bodily experiences, trigger situations, and their management. Therefore, patients may have developed strategies of symptom management focused on emotion avoidance and/or inhibition.

Narcolepsy, Anesthesia, and Sedation: A Survey of the Perioperative Experience of Patients With Narcolepsy

BACKGROUND

Patients with narcolepsy may be at increased perioperative risk due to the interactions among anesthesia, narcolepsy, and narcolepsy medications. This study sought to determine the perioperative experience of narcoleptic patients undergoing anesthesia or sedation, the frequency of perioperative counseling, and self-reported surgical complications.

METHODS

A 22-question survey was developed by expert consensus and distributed by the Narcolepsy Network. Recruitment was via the Narcolepsy Network's list-serve and a Facebook link to the survey. One thousand and twenty respondents reported a diagnosis of narcolepsy and 1 or more procedures under anesthesia or sedation. Descriptive, comparative statistics and logistic regression were utilized.

RESULTS

Respondents were mostly women (79.5%) and Caucasian (84.9%), with a mean age of 45 ± 16 years. Most respondents did not receive counseling regarding the possibility of increased sleepiness (70%), cataplexy (90%), or drowsy driving (59%) postanesthesia. More than half of respondents reported adverse events (medication withdrawal symptoms, inadequate pain relief, increased cataplexy). Subjects with cataplexy more frequently reported surgical complications (70% vs 31%; P = .03) and medication withdrawal symptoms (stimulant medications: odds ratio, 3.0 [95% CI, 1.9, 3.06]; P > .001 and antidepressant medications: odds ratio, 6.5 [95% CI, 2.1-19.5]; P = .001). Of the total sample, 18% indicated surgical complications. Undergoing 5 or more separate surgeries or procedures was associated with a 2-fold increase in self-reported complications (odds ratio, 2.2 [95% CI, 1.3-3.4]; P = .001), difficulty waking (odds ratio, 2.1 [95% CI, 1.45-3.06]; P = .001), and inadequate pain relief (odds ratio, 1.77 [95% CI, 1.01-3.13]; P < .05).

CONCLUSIONS

Most narcoleptic patients report not receiving counseling regarding potential worsening of narcolepsy symptoms postanesthesia or an increased risk of drowsy driving. Enhanced education of perioperative providers about potential narcolepsy-related issues is essential. Respondents frequently self-report adverse events in the perioperative period. Future studies should clarify the perioperative risk associated with narcolepsy to optimize the care and safety of narcoleptic patients.

First-Trimester Pregnancy Exposure to Modafinil and Risk of Congenital Malformations

This study uses pharmacoepidemiology data from Danish national health registries to examine the association between first-trimester exposure to modafinil and risk of major congenital malformations.

Knowledge Gaps in the Perioperative Management of Adults With Narcolepsy: A Call for Further Research

There is increasing awareness that sleep disorders may be associated with increased perioperative risk. The Society of Anesthesia and Sleep Medicine created the Narcolepsy Perioperative Task Force: (1) to investigate the current state of knowledge of the perioperative risk for patients with narcolepsy, (2) to determine the viability of developing perioperative guidelines for the management of patients with narcolepsy, and (3) to delineate future research goals and clinically relevant outcomes. The Narcolepsy Perioperative Task Force established that there is evidence for increased perioperative risk in patients with narcolepsy; however, this evidence is sparse and based on case reviews, case series, and retrospective reviews. Mechanistically, there are a number of potential mechanisms by which patients with narcolepsy could be at increased risk for perioperative complications. These include aggravation of the disease itself, dysautonomia, narcolepsy-related medications, anesthesia interactions, and withdrawal of narcolepsy-related medications. At this time, there is inadequate research to develop an expert consensus or guidelines for the perioperative management of patients with narcolepsy. The paucity of available literature highlights the critical need to determine if patients with narcolepsy are at an increased perioperative risk and to establish appropriate research protocols and clearly delineated patient-centered outcomes. There is a real need for collaborative research among sleep medicine specialists, surgeons, anesthesiologists, and perioperative providers. This future research will become the foundation for the development of guidelines, or at a minimum, a better understanding how to optimize the perioperative care of patients with narcolepsy.

Epidemiology of neurologic disease in pregnancy

Many neurologic diseases in women are influenced by the physiologic and hormonal changes of pregnancy, and pregnancy itself poses challenges in both treatment and evaluation of these conditions. Some diseases, such as epilepsy and multiple sclerosis, have a high enough prevalence in the young female population to support robust epidemiologic data while many other neurologic diseases, such as specific myopathies and muscular dystrophies, have a low prevalence, with data limited to case reports and small case series. This chapter features epidemiologic information regarding a breadth of neurologic conditions, including stroke, epilepsy, demyelinating disease, peripheral neuropathies, migraine, sleep-disordered breathing, and meningioma, in women in the preconception, pregnancy, and postpartum stages.

Sleep and sleep disorders in pregnancy

Pregnancy is associated with a number of physiologic changes in the body including hormonal, anatomical, and mechanical. These changes alter many physiologic functions including sleep. The literature suggests that a number of women develop changes in duration, pattern, and quality of sleep during pregnancy. In addition, these changes also pave the way for expression of sleep disorders (e.g., insomnia, obstructive sleep apnea, and restless legs syndrome). Change in sleep and appearance of sleep disorders not only influence pregnant women, but also have negative influences on the fetus and outcomes of pregnancy. However, optimal management of these disorders may reverse adverse consequences. In this chapter, risk factors, clinical presentation, and management of insomnia, obstructive sleep apnea, and restless legs syndrome during pregnancy are discussed in view of the available literature.

Pregnancy and Contraception Experiences in Women With Narcolepsy: A Narcolepsy Network Survey

STUDY OBJECTIVES

To explore knowledge and experiences of women with narcolepsy on pregnancy and contraception issues and their relationships with narcolepsy pharmacotherapy.

METHODS

An 18-item survey was administered through the Narcolepsy Network website for 8 weeks during the fall of 2012. The survey ascertained demographic information; prescription narcolepsy medication use and discontinuation during pregnancy; physician counseling regarding pregnancy, contraception, and medication usage; and pregnancy history and outcomes. Frequencies of responses were analyzed and compared between pharmacotherapy groups.

RESULTS

Surveys from 182 women (age 41.5 ± 15.2 years) with narcolepsy were analyzed. Most of the respondents (78.7%) who reported a history of pregnancy did not use pharmacotherapy during pregnancy. Most of them discontinued narcolepsy pharmacotherapy during pregnancy because of their own fear of harming the fetus (82.9%), and 58.5% noted advice of discontinuation from their narcolepsy physician as a factor in their decision. As an alternative to pharmacotherapy, 72.1% of women extended their sleep time, 32.6% discontinued working, and 27.9% discontinued driving. Similar pregnancy and fetal outcomes were reported between women using monotherapy, polytherapy, or no therapy during pregnancy, but some outcomes were worse than national averages. In general, women with narcolepsy were dissatisfied with the amount and type of counseling that they received regarding pregnancy and contraception.

CONCLUSIONS

Improved health education counseling and symptom management options are needed for women with narcolepsy to improve pregnancy management and outcomes in this population.

Sleep Pharmacotherapy for Common Sleep Disorders in Pregnancy and Lactation

Sleep disturbances are common in pregnancy, and sleep disorders may worsen or present de novo in the course of gestation. Managing a pregnant patient is complicated by the risk of teratogenicity, pharmacokinetic changes, and the dynamic nature of pregnancy. Although nonpharmacologic interventions are likely safest, they are often ineffective, and a patient is left dealing with frustrations of the sleep disturbance, as well as the negative outcomes of poor sleep in pregnancy. As with any other condition in pregnancy, management requires an understanding of pregnancy physiology, knowledge of the impact of a given condition on pregnancy or fetal and neonatal outcomes, and an ability to weigh the risk of the exposure to an untreated, or poorly treated condition, against the risk of a given drug. In partnership with the pregnant patient or couple, options for therapy should be reviewed in the context of the impact of the condition on pregnancy and offspring outcomes, while understanding that data (positive or negative) on the impact of therapy on perinatal outcomes are lacking. This article reviews the epidemiology of sleep disorders in pregnancy, general principles of prescribing in pregnancy and lactation, and safety surrounding therapeutic options in pregnancy.

Oral L-Carnitine used to treat narcoleptic type 1 patient during pregnancy - A case report

Narcolepsy type 1 is a sleep disorder characterized by excessive daytime sleepiness (EDS), sleep fragmentation, hypnagogic hallucinations, sleep paralysis, and cataplexy. Stimulant medications such as modafinil and amphetamines are the first-line medications for treating sleepiness. However, the management of narcolepsy during special circumstances of life such as pregnancy is complex. MMDM is a 34-year-old female with Narcolepsy type 1 treated with modafinil (400mg/d) and citalopram (20mg/d). Before she become pregnant, modafinil and citalopram were replaced for L-Carnitine 510mg/d with good outcome. She underwent an usual pregnancy and was submitted to a term cesarean delivery without child-birth complications. This is the first description of oral L-Carnitine such an alternative to treatment narcolepsy type 1 during pregnancy. Treat these patients is not easy but care narcolepsy pregnant is a challenging even bigger. In a disease without many treatment options, L-Carnitine can be used to treat daytime sleepiness during pregnancy in narcolepsy.

Evaluating Transfer of Modafinil Into Human Milk During Lactation: A Case Report

ABSTRACT

We present a case of a 27-year-old woman in whom idiopathic hypersomnolence was diagnosed in adolescence with adequate symptomatic control on daily dosage of 250 mg of modafinil. She maintained this dosage throughout her pregnancy and during the peripartum period, but did not breastfeed her newborn because of a lack of information on the transmission of modafinil in human breast milk. Samples of her breast milk were obtained at various times over a 24-hour period and analyzed using liquid chromatography mass spectrometry. The relative infant dose was calculated to be 5.3%, below the threshold of concern for drug passage via breast milk. This is the first reported case of modafinil transfer into human breast milk. Given the drug's use in a variety of sleep disorders, the results of this case can be used to advise breastfeeding mothers prescribed modafinil.

Pharmacologic Treatment of Sleep Disorders in Pregnancy

Pregnancy often predisposes women to new-onset sleep disturbances, as well as exacerbations of preexisting sleep disorders. The goals of treating perinatal sleep disorders include the promotion of restorative sleep and the benefits it brings to both mother and fetus. The prescribing of any sleep aid in pregnancy must include consideration of the risks and benefits for both the patient and her fetus. Although data on the perinatal use of sleep aids is limited, there may be effects on fetal development, timing and duration of delivery, and postnatal outcomes.

Anesthetic Management of Narcolepsy Patients During Surgery: A Systematic Review

BACKGROUND

Narcolepsy is a rare sleep disorder characterized by excessive daytime sleepiness, sleep paralysis, and/or hypnagogic/hypnopompic hallucinations, and in some cases cataplexy. The response to anesthetic medications and possible interactions in narcolepsy patients is unclear in the perioperative period. In this systematic review, we aim to evaluate the current evidence on the perioperative outcomes and anesthetic considerations in narcolepsy patients.

METHODS

Electronic literature search of Medline, Medline in-process, Embase, Cochrane Database of Systematic Reviews databases, international conference proceedings, and abstracts was conducted in November 2015 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guideline. A total of 3757 articles were screened using a 2-stage strategy (title-abstract followed by full text). We included case studies/series, cohort studies, and randomized controlled trials of narcolepsy patients undergoing surgical procedures under anesthesia or sedation. Preoperative narcolepsy symptoms and sleep study data, anesthetic technique, and perioperative complications were extracted. Screening of articles, data extraction, and compilation were conducted by 2 independent reviewers and any conflict was resolved by the senior author.

RESULTS

A total of 19 studies including 16 case reports and 3 case series were included and evaluated. The majority of these patients received general anesthesia, whereas a small percentage of patients received regional anesthesia. Reported complications of narcolepsy patients undergoing surgeries were mainly related to autonomic dysregulation, or worsening of narcolepsy symptoms intra/postoperatively. Narcolepsy symptoms worsened only in those patient populations where the preoperative medications were either discontinued or reduced (mainly in obstetric patients). In narcolepsy patients, use of depth of anesthesia monitoring and total intravenous technique may have some advantage in terms of safety profile. Several patients undergoing neurosurgery involving the hypothalamus or third or four ventricles developed new-onset narcolepsy.

CONCLUSIONS

We found a paucity of prospective clinical trials in this patient population, as most of the studies were case reports or observational studies. Continuation of preoperative medications, depth of anesthesia monitoring, use of multimodal analgesia with short-acting agents and regional anesthesia techniques were associated with favorable outcomes. Obstetric patients may be at greater risk for worsening narcolepsy symptoms, possibly related to a reduction or discontinuation of medications. For neurosurgical procedures involving the hypothalamus or third and fourth ventricle, postoperative considerations should include monitoring for symptoms of narcolepsy. Future studies are needed to better define perioperative risks associated with anesthesia and surgery in this population of patients.

Parental Fitness Questioned on the Grounds of Narcolepsy: Presentation of Two Cases

ABSTRACT

We report two cases of fathers whose parental fitness was questioned during divorce and custody litigation because of narcolepsy type 2 and type 1, respectively. These cases highlighted both the existence of a narcolepsy-related stigma and the need to involve sleep experts in custody assessments when concerns about the parental fitness are related to a sleep disorder, expanding the field of interest of the growing "sleep forensics."

Narcolepsy with cataplexy and pregnancy: a case-control study

This was a retrospective case-control study in 25 patients with narcolepsy with cataplexy and 75 women in the control group. Patients completed the questionnaire by Maurovich-Horvat et al. (J. Sleep Res., 2013, 22: 496-512). We personally interviewed 25 patients with narcolepsy with cataplexy using the administered questionnaire regarding conception, pregnancy, delivery, perinatal and breastfeeding periods. Patients with narcolepsy with cataplexy reported 59 pregnancies versus 164 in the control group. In 16 cases (27.1%), a disease before pregnancy was present compared with eight cases (4.9%) in the control group (P < 0.001); among them, extrinsic asthma was reported 11 times in the narcolepsy with cataplexy group (P < 0.005). Patients with narcolepsy with cataplexy more often had a single pregnancy compared with controls (P < 0.05). Gestational diabetes was more frequent in patients with narcolepsy with cataplexy (P < 0.05). Induced deliveries were higher in controls (P < 0.009). No differences were found between the groups in terms of duration of pregnancies and complications during and after delivery, as during the puerperium. Neonates from patients had heavier birth weight (P < 0.015). The breastfeeding period was longer in patients (P < 0.01). Modafinil and methylphenidate were the drugs administered in six pregnancies. No significant differences in depression during pregnancy and during puerperium were found between patients and controls. This is the first case-control study in women with narcolepsy with cataplexy related to pregnancy, delivery, childbirth and puerperium. Data suggest that patients have pregnancy outcomes similar to controls. The prevalence of gestational diabetes was higher in women with narcolepsy with cataplexy. Caesarean sections, complications during delivery and normal perinatal period for infants were similar in both groups. Breastfeeding was longer in patients.

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.

Narcolepsy in children: a diagnostic and management approach

OBJECTIVE

To provide a diagnostic and management approach for narcolepsy in children.

METHODS

Narcolepsy is a chronic disabling disorder characterized by excessive daytime sleepiness, cataplexy, hypnogogic and/or hypnopompic hallucinations, and sleep paralysis. All four features are present in only half of the cases. Excessive daytime sleepiness is the essential feature of narcolepsy at any age and is usually the first symptom to manifest. A combination of excessive daytime sleepiness and definite cataplexy is considered pathognomonic of narcolepsy syndrome.

RESULTS

New treatment options have become available over the past few years. Early diagnosis and management can significantly improve the quality of life of patients with narcolepsy with cataplexy.

CONCLUSION

This review summarizes the pathophysiology, clinical features, and management options for children with narcolepsy.

[Narcolepsy]

Narcolepsy is a rare sleep disorder. The classical presentation includes the four symptoms excessive daytime sleepiness, cataplexy, sleep paralysis and hypnagogic hallucinations. As a model disease with all the transitions from awake to sleeping conditions, non-rapid eye movement (NREM) and rapid eye movement (REM), it plays an important role in neurology and sleep medicine. Patients with narcolepsy possess a reduced number of hypocretin-producing neurons in the hypothalamus and accordingly the hypocretin level in the cerebrospinal fluid is low. The neuropeptide hypocretin (orexin) has functions, such as the regulation of the sleep-wake cycle, the autonomous nerve system, motor system and metabolic processes. The delay in diagnosing narcolepsy is difficult to comprehend in modern medicine. The frequent association with other sleep-wake disorders may be responsible for the delay. Genomewide association studies have subsequently been able to prove that autoimmune mechanisms are responsible for the manifestation of narcolepsy with the HLA association being the most important for susceptibility and protection. Imaging studies have revealed neurodegenerative changes, making a multifactorial etiopathogenesis probable. The frequent occurrence of metabolic disorders has not yet been clarified. Early diagnosis of narcolepsy has the possibility to offer affected persons an adequate medication to lead an almost normal life and the future possibility to cure narcolepsy through immunomodulation therapy.

Sleep disorders in pregnancy

Sleep disturbances are common in pregnancy and may be influenced by a multitude of factors. Pregnancy physiology may predispose to sleep disruption but may also result in worsening of some underlying sleep disorders, and the de novo development of others. Apart from sleep disordered breathing, the impact of sleep disorders on pregnancy, fetal, and neonatal outcomes is poorly understood. In this article, we review the literature and discuss available data pertaining to the most common sleep disorders in perinatal women. These include restless legs syndrome, insomnia, circadian pattern disturbances, narcolepsy, and sleep-disordered breathing.

The relationship and potential mechanistic pathways between sleep disturbances and maternal hyperglycemia

This paper reviews recent work investigating the influence of sleep disturbances on maternal hyperglycemia, particularly gestational diabetes mellitus (GDM). The incidence and prevalence of hyperglycemia are increasing worldwide, which is cause for concern because GDM and even mild hyperglycemia are associated with adverse pregnancy outcomes. A better understanding of sleep-related risk factors for maternal hyperglycemia is an important health matter. Evidence demonstrates associations between sleep disturbances, especially sleep-disordered breathing, and hyperglycemia, but causal effects and the underlying mechanisms linking these conditions have not been fully elucidated. Subjective sleep assessments show associations between sleep disturbances and maternal hyperglycemia. There are, however, few studies using objective measures to support these findings. Large prospective studies are required to examine causal relationships between sleep disturbances and maternal hyperglycemia. There is also a need for smaller mechanistic studies to understand the pathophysiology. Furthermore, interventional studies are required to address whether improvement of sleep parameters can prevent/decrease the risk of developing maternal hyperglycemia. Taken together, the data suggests that sleep disturbances during pregnancy are important to identify and manage in order to minimize maternal hyperglycemia and GDM, and improve maternal and fetal well-being.