Sleep disordered breathing in pregnancy

[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.

Objective and self-reported assessment of sleep quality during each trimester of pregnancy: A prospective observational study

OBJECTIVES

Studies on actual circumstances of sleep in pregnant women are limited to surveys of self-reported symptoms, and objective assessments are missing. Sleep disturbances due to hormonal imbalances are common during pregnancy. This study aimed to assess sleep quality by objective assessment using an actigraph and by self-reported assessment using a questionnaire for sleep during each trimester of pregnancy and to elucidate how sleep quality changed from the first to the third trimester of pregnancy.

STUDY DESIGN

A longitudinal questionnaire survey was administered and sleep measurements using an actigraph were recorded at three time points during the first, second, and third trimesters in primiparous women who had conceived naturally.

RESULTS

During the first trimester, "feeling of being refreshed when waking up in the morning" was not noted, and a decline was observed in mental function. During the second trimester, a positive correlation was observed between morning sickness and sleep quality.

CONCLUSIONS

Sleep quality was the worst during the third trimester, with the shortest total sleep time and poor sleep efficiency, along with poor physical function scores. Back pain and leg cramps significantly correlated with sleep efficiency in the third trimester. Poor sleep during pregnancy begins in the first trimester. If minor problems, such as morning sickness, continue in the second trimester, sleep quality is greatly affected. Furthermore, during the third trimester of pregnancy, low back pain and leg cramps are more likely to occur due to an increase in the abdominal area and may interfere with sleep.

Validation of a sleep-disordered breathing screening questionnaire during pregnancy and comparison between mothers and bedpartners prediction of risk

BACKGROUND

Sleep Disorder Breathing (SDB) in pregnant patients ranges from 3 to 27% and varies depending on gestational age and method used to diagnose. SDB increases the risk of advanced pregnancy complications such as gestational diabetes mellitus, pregnancy-induced hypertension, and preeclampsia. Screening and diagnosis of SDB during pregnancy remains a challenge, with existing screening tools underperforming during pregnancy. This study aimed to validate a previously developed model for predicting SDB during late pregnancy and compare the predictive value of bedpartner responses.

METHODS

Ninety-six women in the third trimester of pregnancy underwent polysomnography and completed the Berlin Questionnaire (BQ), with 81 bedpartners completing the BQ about their pregnant partner. A subset of BQ items (snoring volume and tiredness upon awakening) along with BMI > 32 kg/m2 was utilised to calculate the Wilson Optimized Model (WOM), which demonstrated strong predictive properties in development.

RESULTS

SDB (RDI/hr ≥ 5) was detected in 43.8% of women. BQ identified 72% of pregnant mothers as high risk for SDB (Sensitivity = 83%, Specificity = 37%), compared to 29% of mothers identified by the WOM (Sensitivity = 45%, Specificity = 83%). At RDI of ≥ 15, the WOM correctly classified more women according to SDB risk than the BQ (76.0% vs. 41.7% cases correct, X2(1) = 23.42, p < .001), with no difference at RDI ≥ 5. Bedpartners were more likely to report high risk for SDB on the WOM than pregnant women themselves (38.3% vs. 28.4%), however predictive ability was not improved by bedpartner input (RDI ≥ 5 bedpartner AUC = 0.69 v mother AUC = 0.73).

CONCLUSION

BQ largely overestimates the prevalence of SDB in pregnancy compared to the WOM which underestimates. Utilising bedpartner responses didn't improve screening for SDB in late pregnancy. More work is needed to develop a pregnancy-specific tool for quick and accurate screening for SDB.

Screening Tools for Obstructive Sleep Apnea in Pregnant Women: An Extended and Updated Systematic Review and Meta-analysis

The prevalence of obstructive sleep apnea syndrome (OSA) increases in women during pregnancy and negatively affects maternal and fetal outcomes. The updated systematic review and meta-analysis aimed to evaluate the validity of the Berlin, STOP-Bang, and Epworth sleepiness scale (ESS) questionnaires in detecting OSA in pregnant women. PubMed, Embase, and Web of Science were searched systematically up to March 2022. After eligible studies inclusion, two independent reviewers extracted demographic and clinical data. Bivariate random effects models were used to estimate the pooled accuracy measures including sensitivity and specificity, positive (PPV) and negative predictive values (NPVs), diagnostic odds ratio (DOR), and receiver operating characteristic curve (ROC) curve. We included 8 studies including 710 pregnant women with suspected OSA. The performance values of Berlin, STOP-Bang, and ESS questionnaires were as follows: the pooled sensitivity were 61% (95% confidence interval (CI): 40%-80%), 59% (95% CI: 49%-69%), and 29%, (95% CI: 10%-60%); pooled specificity were 61% (95% CI: 42%-78%), 80% (95% CI: 55%-93%), and 80% (95% CI: 50%-94%); pooled PPVs were 60% (95% CI: 0.49-0.72), 73% (95% CI: 61%-85%), and 59% (95% CI: 31%-87%); pooled NPVs were 60% (95% CI: 0.49-0.71), 65% (95% CI: 54%-76%), and 53% (95% CI: 41%-64%); and pooled DORs were 3 (95% CI: 1-5), 6 (95% CI: 2-19), and 2 (95% CI: 1-3), respectively. It seems that the Berlin, STOP-Bang, and ESS questionnaires had poor to moderate sensitivity and specificity in pregnancy, with the ESS showing the worst characteristics. Further studies are required to evaluate the performance of alternative screening methods for OSA in pregnancy.

Application of portable sleep monitoring devices in pregnancy: a comprehensive review

Objective.The physiological, hormonal and biomechanical changes during pregnancy may trigger sleep disordered breathing (SDB) in pregnant women. Pregnancy-related sleep disorders may associate with adverse fetal and maternal outcomes including gestational diabetes, preeclampsia, preterm birth and gestational hypertension. Most of the screening and diagnostic studies that explore SDB during pregnancy were based on questionnaires which are inherently limited in providing definitive conclusions. The current gold standard in diagnostics is overnight polysomnography (PSG) involving the comprehensive measurements of physiological changes during sleep. However, applying the overnight laboratory PSG on pregnant women is not practical due to a number of challenges such as patient inconvenience, unnatural sleep dynamics, and expenses due to highly trained personnel and technology. Parallel to the progress in wearable sensors and portable electronics, home sleep monitoring devices became indispensable tools to record the sleep signals of pregnant women at her own sleep environment. This article reviews the application of portable sleep monitoring devices in pregnancy with particular emphasis on estimating the perinatal outcomes.Approach.The advantages and disadvantages of home based sleep monitoring systems compared to subjective sleep questionnaires and overnight PSG for pregnant women were evaluated.Main Results.An overview on the efficiency of the application of home sleep monitoring in terms of accuracy and specificity were presented for particular fetal and maternal outcomes.Significance.Based on our review, more homogenous and comparable research is needed to produce conclusive results with home based sleep monitoring systems to study the epidemiology of SDB in pregnancy and its impact on maternal and neonatal health.

Sleep disturbance and its associated factors among pregnant women in Ethiopia: systematic review and meta-analysis

INTRODUCTION

Globally, sleep disturbance is the foremost public health issue among pregnant women which might have undesirable birth outcome including neurocognitive impairment, preterm birth, low birth weight, and neonatal morbidity and mortality. In Ethiopia, inconsistent findings have been reported on the prevalence of sleep disturbance among pregnant women. Therefore, this review aims to estimate the pooled prevalence sleep disturbance and its associated factors among pregnant women in Ethiopia.

METHODS

This systematic review and meta-analysis of observational studies was designed according to the PRISMA guideline. A systematic search of literature was conducted in PubMed, Scopus, Web of science, and Google Scholar using relevant searching key terms. The Newcastle-Ottawa scale was used to evaluate the quality of all selected articles. Data were analyzed using STATA Version 14 software. Publication bias was checked using Egger's test and funnel plot. Cochran's chi-squared test and I2 values were used to assess heterogeneity. A fixed-effects model was applied during meta-analysis.

RESULTS

In this review, six studies were included after reviewing 17,100 articles. The pooled prevalence of sleep disturbance among pregnant women in Ethiopia was 50.43% (95%CI: 39.34-61.52). Third trimester pregnancy AOR = 4.03; 95% CI: 2.84,5.71), multigravidity (AOR = 1.99; 95% CI: 1.54, 2.59), unplanned pregnancy (AOR = 2.56; 95% CI: 1.52,4.31), depression (AOR = 3.57; 95% CI: 2.04, 6.27), stress (AOR = 2.77; 95% CI: 1.57, 4.88), anxiety (AOR = 3.69; 95% CI: 1.42, 9.59) and poor sleep hygiene (AOR = 2.49; 95% CI: 1.56, 3.99) and were statistically associated with sleep disturbance among pregnant women.

CONCLUSION

This review revealed that the magnitude of sleep disturbance among pregnant woman in Ethiopia was relatively high and multiple factors determined the likelihood of having a disturbed sleep-awake pattern. Thus, the implementation of interventions for sleep disturbance after screening pregnant women is needed. Moreover, public health interventions targeted on the prevention of unintended pregnancy and depression during pregnancy should be implemented.

Treatable traits in asthma during pregnancy: a call for a shift towards a precision-based management approach

Asthma is the most common chronic medical condition in pregnancy. Asthma exacerbations in pregnancy are unpredictable, and are associated with adverse maternal and fetal perinatal outcomes such as preterm birth and low birthweight. Goals of asthma management in pregnancy are to establish effective asthma control and prevent exacerbations. Optimising the management of asthma in pregnancy is an important goal of practice and future research.Treatable traits is a precision medicine paradigm proposed for the management of airways diseases, which holistically addresses the complexity and heterogeneity of airways disease. It is an individualised treatment approach that aims to improve outcomes. This makes treatable traits well suited for pregnant women with asthma, who have a high prevalence of obesity, mental health conditions, poor symptom perception and suboptimal asthma management skills including low treatment adherence. These traits are measurable and treatable. In this review, we explore current knowledge on the burden of asthma, maternal and perinatal consequences of asthma during pregnancy, the treatable traits paradigm, the prevalence of treatable traits in pregnant women with asthma, and consider how the treatable traits paradigm can be integrated into the management of asthma in pregnancy.

PsyNBIOsis: Investigating the Association between Maternal Gestational Diabetes, Mental Health, Diet and Childhood Obesity Risk: Protocol for a Prospective, Longitudinal, Observational Study

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with poorer maternal mental health (depression and anxiety). Maternal mental health and GDM are likely to influence diet, which in turn impacts the course of GDM. Maternal diet may also be directly or indirectly associated with changes in infant anthropometry. The aims of this study are to (1) examine the associations between maternal GDM, mental health and diet, and (2) evaluate the associations between these maternal factors, breastmilk composition and infant anthropometry.

METHODS

This prospective, observational, longitudinal cohort study compares a cohort of women with and without GDM. Maternal mental health and diet are assessed using validated questionnaires. Breastmilk composition is measured with the Human Milk Analyzer, and infant body composition is measured with air displacement plethysmography.

SIGNIFICANCE AND IMPACT

Once data have been collected, PsyNBIOsis will provide evidence for the associations between maternal mental health, GDM status and diet, and their impact on breastmilk composition and early infant growth. The results may inform the Developmental Origins of Health and Disease framework and provide data on which to build cost-effective interventions to prevent both the development of mental health issues in mothers and adverse growth patterns in infants.

Racial/ethnic disparities in sleep-disordered breathing during pregnancy in the nuMoM2b study

OBJECTIVE

The aim of this study was to assess the prevalence and severity of sleep-disordered breathing (SDB) across racial/ethnic groups in 3702 pregnant people at 6 to 15 and 22 to 31 weeks gestational age, examine whether BMI modifies the association between race/ethnicity and SDB, and investigate whether interventions to reduce weight might reduce racial/ethnic disparities in SDB.

METHODS

Differences by race/ethnicity in SDB prevalence and severity were quantified via linear, logistic, or quasi-Poisson regression. Controlled direct effect was used to estimate whether intervening on BMI would remove/diminish differences by race/ethnicity in SDB severity.

RESULTS

This study comprised 61.2% non-Hispanic White (nHW), 11.9% non-Hispanic Black (nHB), 18.5% Hispanic, and 3.7% Asian people. SDB prevalence was higher for nHB compared with nHW pregnant people at 6 to 15 weeks (odds ratio [OR] 1.81, 95% CI [1.07, 2.97]), whereas at 21 to 32 weeks, Asian pregnant people had a higher SDB prevalence than nHW (OR 2.2, 95% CI [1.1, 4.0]). The severity of SDB differed across racial/ethnic groups in early pregnancy, with nHB pregnant people having a higher apnea-hypopnea index (AHI) (OR 1.35, 95% CI [1.07, 1.69]) compared with nHW. Having overweight/obesity was associated with a higher AHI (β = 2.36, 95% CI [1.97, 2.84]). Controlled direct effect analyses indicated that in early pregnancy, nHB and Hispanic pregnant people would have a lower AHI compared with nHW people had they had normal weight.

CONCLUSIONS

This study extends knowledge on racial/ethnic disparities in SDB to a pregnant population.

Metabolic dysregulation and decreased capillarization in skeletal muscles of male adolescent offspring rats exposed to gestational intermittent hypoxia

Gestational intermittent hypoxia (IH) is a hallmark of obstructive sleep apnea that occurs frequently during pregnancy, and effects caused by this environmental change during pregnancy may be transmitted to the offspring. In this study, we aimed to clarify the effects of IH in pregnant rats on the skeletal muscle of adolescent offspring rats. Mother rats underwent IH from gestation day 7-21, and their 5-weeks-old male offspring were analyzed. All male offspring rats were born and raised under normoxia conditions. Although no general growth retardation was observed, we found that exposure to gestational IH reduces endurance running capacity of adolescent offspring rats. Both a respiratory muscle (diaphragm; DIA) and a limb muscle (tibialis anterior; TA) showed no histological abnormalities, including fiber size and fiber type distribution. To identify the possible mechanism underlying the reduced running capacity, regulatory factors associated with energy metabolism were analyzed in different parts of skeletal muscles. Compared with rats born under conditions of gestational normoxia, gestational IH offspring rats showed significantly lower expression of genes associated with glucose and lipid metabolism, and lower protein levels of phosphorylated AMPK and AKT. Furthermore, gene expression of adiponectin receptors one and two was significantly decreased in the DIA and TA muscles. In addition, the DIA muscle from adolescent rats had significantly decreased capillary density as a result of gestational IH. However, these changes were not observed in a sucking muscle (geniohyoid) and a masticating muscle (masseter) of these rats. These results suggest that respiratory and limb muscles are vulnerable to gestational IH, which induces altered energy metabolism with decreased aerobic motor function. These changes were partially owing to the decreased expression of adiponectin receptors and decreased capillary density in adolescent offspring rats.

Obstructive Sleep Apnea and Risk of Miscarriage

The purpose of this project was to evaluate whether screening positive on obstructive sleep apnea questionnaires in the first trimester of pregnancy was associated with miscarriage. This was a secondary analysis of a prospective observational cohort study of participants who were screened for sleep apnea during pregnancy with the Epworth Sleepiness Scale, Berlin Questionnaire, and novel items related to sleep and napping. This secondary analysis was IRB exempt. Our primary outcome was miscarriage in the index pregnancy. An association between responses to the sleep apnea screening questions with miscarriage of the index pregnancy was queried via Poisson regression. We found that gravidae who had elevated scores on both the Epworth Sleepiness Scale and the Berlin Questionnaire were more likely to experience miscarriage than those who had elevated scores on only one questionnaire or neither (p = 0.018). Gravidae who reported snoring (p = 0.042) or hypertension (p = 0.013) in the first trimester were more likely to experience miscarriage than gravidae who did not. Gravidae who reported napping in the first trimester were less likely to experience miscarriage (p = 0.045), even after adjusting for confounding variables (p = 0.007). In conclusion, we found that screening positive on both the Berlin Questionnaire and Epworth Sleepiness Scale was statistically significantly associated with miscarriage prior to adjustment for confounding variables, as did snoring and hypertension. After adjusting for confounding variables, only not napping was associated with miscarriage. Given the small sample size, further investigation into this topic is warranted.

Effects of Gestational Sleep Patterns and Their Changes on Maternal Glycemia and Offspring Physical Growth in Early Life

Maternal sleep patterns during pregnancy are drawing increased attention to examine its role in the regulation of maternal glycemia and physical growth of offspring within 24 months. Among 3329 eligible mother−child pairs included in the Shanghai Maternal−Child Pairs Cohort, sleep patterns of pregnant women were assessed by Pittsburgh Sleep Quality Index and objective measurement in early and late pregnancy. Offspring physical growth within 24 months was primarily indicated by the body mass index Z-score (BAZ), catch-up growth, and overweight/obesity. In total, 3329 and 382 pregnant women were included with subjectively assessed and objectively measured sleep pattern, respectively. The increased risk of GDM was associated with maternal night-time sleep duration ≥8.5 h in early pregnancy, or sleep quality change from poor to good during pregnancy (OR = 1.48; 95% CI, 1.06 to 2.07). In the GDM group, the effect of sleep duration in early pregnancy on overweight/obesity in offspring within 24 months showed a U-shaped curve, with a 1.73-fold and 1.43-fold increased risk of overweight/obesity of offspring in pregnant women with <7.5 or ≥8.5 h of sleep duration, respectively. A good gestational sleep pattern was required to reduce the risk of GDM and offspring overweight/obesity within 24 months.

Association between sleep quality, hypertensive disorders of pregnancy, and sleep-disordered breathing in pregnant women with and without obesity: An observational cross-sectional study

AIM

To elucidate whether pregnancy and obesity are associated with poor sleep quality, and to investigate if sleep quality is associated with hypertensive disorders of pregnancy in pregnant women with obesity.

METHODS

This observational cross-sectional study examined 15 obese pregnant women (body mass index ≥30 kg/m² ) (p-Ob group), 15 nonobese pregnant women (p-nOb group), and 30 nonobese nonpregnant women (n-Pr group), using home recording devices to monitor sleep-disordered breathing (SDB): respiratory disturbance index, oxygen saturation, and sleep stage and quality. These variables were compared among the groups. Moreover, obese women with and without hypertensive disorders of pregnancy were compared.

RESULTS

Significant differences in respiratory disturbance index (median: 10.3 [p-Ob], 7.1 [p-nOb], 3.5 [n-Pr]) and oxygen saturation (95.1%, 96.5%, and 96.6%) were observed among the groups. Seven participants in the p-Ob group experienced hypertensive disorders of pregnancy with SDB before or after sleep examination. Particularly, those who developed hypertensive disorders of pregnancy before sleep examination showed a lower delta power throughout the night than those without this condition.

CONCLUSION

Pregnant women had poor sleep quality; those with obesity had higher frequency of SDB with worsened respiratory conditions that might cause complications. Our findings suggest that the development of hypertensive disorders of pregnancy in some obese pregnant women might be associated with insufficient delta power. Focusing on delta power may reflect subtle changes in sleep quality that occur in pregnant women. Future longitudinal studies with larger sample sizes are required to confirm these findings and investigate causality.

Sleep-disordered Breathing in Pregnancy and after Delivery: Associations with Cardiometabolic Health

Rationale: Knowledge gaps exist regarding health implications of sleep-disordered breathing (SDB) identified in pregnancy and/or after delivery. Objectives: To determine whether SDB in pregnancy and/or after delivery is associated with hypertension (HTN) and metabolic syndrome (MS). Methods: nuMoM2b-HHS (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be Heart Health Study) (N = 4,508) followed participants initially recruited during their first pregnancy. Participants returned for a visit 2-7 years after pregnancy. This study examined a subgroup who underwent SDB assessments during their first pregnancy (n = 1,964) and a repeat SDB assessment after delivery (n = 1,222). Two SDB definitions were considered: 1) apnea-hypopnea index (AHI) ⩾ 5 and 2) oxygen desaturation index (ODI) ⩾ 5. Associations between SDB and incident HTN and MS were evaluated with adjusted risk ratios (aRRs). Measurements and Main Results: The aRR for MS given an AHI ⩾ 5 during pregnancy was 1.44 (95% confidence interval [CI], 1.08-1.93), but no association with HTN was found. ODI ⩾ 5 in pregnancy was associated with both an increased risk for HTN (aRR, 2.02; 95% CI, 1.30-3.14) and MS (aRR, 1.53; 95% CI, 1.19-1.97). Participants with an AHI ⩾ 5 in pregnancy that persisted after delivery were at higher risk for both HTN (aRR, 3.77; 95% CI, 1.84-7.73) and MS (aRR, 2.46; 95% CI, 1.59-3.76). Similar associations were observed for persistent ODI ⩾ 5 after delivery. Conclusions: An AHI ⩾ 5 in pregnancy was associated with an increased risk of MS. An ODI ⩾ 5 in pregnancy was significantly associated with both HTN and MS. Participants with persistent elevations in AHI and ODI during pregnancy and at 2-7 years after delivery were at the highest risk for HTN and MS. Clinical trial registered with www.clinicaltrials.gov (NCT02231398).

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.

Early developmental outcome in children born to mothers with obstructive sleep apnea

Obstructive sleep apnea (OSA) during pregnancy leads to adverse maternal and perinatal outcomes. There have been limited studies evaluated the effect of intrauterine exposure to maternal OSA on childhood developmental outcomes. This study was aimed to evaluate the early development of children born to mothers with gestational OSA and the impact of continuous positive airway pressure (CPAP) treatment. METHODS: Children aged 6-36 months, born to high risk pregnant mothers who had overnight polysomnography performed, were invited to participate. The Ages and Stages Questionnaires, third edition (ASQ-3), age-specific parent-completed questionnaires determining five developmental domains (communication, gross motor, fine motor, problem-solving, and personal-social) were used for developmental screening. Children who had a score of at least one domain less than -1 SD of age cut-off were determined as having a risk of developmental delay (RDD). RESULTS: There were 159 children (47% male, mean age 18 months) enrolled. The maternal PSG showed non-OSA, mild OSA, and moderate OSA in 14%, 46%, and 40%, respectively. Forty-two children (26%) had RDD, and the most affected domains were fine motor and problem-solving. Maternal moderate OSA was significantly associated with RDD (adjusted OR 5.39, 95%CI 1.11-26.12, P 0.037). Subgroup analysis showed that maternal moderate OSA with no CPAP treatment was significantly associated with RDD (OR 6.43, 95%CI 1.34-30.89, P = 0.020) CONCLUSION: Gestational moderate OSA in high-risk pregnancy mothers likely had a negative effect on early childhood developmental outcomes, particularly the mothers who did not have appropriate CPAP treatment.

Gestational sleep deprivation is associated with higher offspring body mass index and blood pressure

Study Objectives

The objective of this study was to evaluate the association between gestational sleep deprivation and childhood adiposity and cardiometabolic profile.

Methods

Data were used from two population-based birth cohorts (Rhea study and Amsterdam Born Children and their Development study). A total of 3,608 pregnant women and their children were followed up until the age of 11 years. Gestational sleep deprivation was defined as 6 or fewer hours of sleep per day, reported by questionnaire. The primary outcomes included repeated measures of body mass index (BMI), waist circumference, body fat, serum lipids, systolic and diastolic blood pressure (DBP) levels in childhood. We performed a pooled analysis with adjusted linear mixed effect and Cox proportional hazards models. We tested for mediation by birthweight, gestational age, and gestational diabetes.

Results

Gestational sleep deprivation was associated with higher BMI (beta; 95% CI: 0.7; 0.4, 1.0 kg/m²) and waist circumference (beta; 95% CI: 0.9; 0.1, 1.6 cm) in childhood, and increased risk for overweight or obesity (HR; 95% CI: 1.4; 1.1, 2.0). Gestational sleep deprivation was also associated with higher offspring DBP (beta; 95% CI: 1.6; 0.5, 2.7 mmHg). The observed associations were modified by sex (all p-values for interaction < 0.05); and were more pronounced in girls. Gestational diabetes and shorter gestational age partly mediated the seen associations.

Conclusions

This is the first study showing that gestational sleep deprivation may increase offspring’s adiposity and blood pressure, while exploring possible mechanisms. Attention to glucose metabolism and preterm birth might be extra warranted in mothers with gestational sleep deprivation.

Sleep-disordered breathing in pregnancy: a developmental origin of offspring obesity?

Sleep-disordered breathing (SDB) worsens over pregnancy, and obstructive sleep apnea is associated with serious maternal complications. Intrauterine exposures that provoke insulin resistance (IR), inflammation, or oxidative stress may have long-term offspring health consequences. In obesity, worsening maternal SDB appears to be an exposure that increases the risk for both small- or large-for-gestational-age (SGA, LGA, respectively), suggesting distinct outcomes linked to a common maternal phenotype. The aim of this paper is to systematically review and link data from both mechanistic rodent models and descriptive human studies to characterize the impact of maternal SDB on fetal development. A systematic review of the literature was conducted using PubMed, Embase, and CINAHL (01/2000-09/2019). Data from rodent (9 studies) and human models (48 studies, 5 meta-analyses) were included and reviewed using PRISMA guidelines. Evidence from rodent models suggests that intermittent maternal hypoxia results in mixed changes in birth weight (BW) followed by accelerated postnatal growth, while maternal sleep fragmentation results in normal BW followed by later metabolic derangement. Human studies support that maternal SDB is associated with both SGA and LGA, both of which may predispose offspring to later obesity. Evidence also suggests a link between SDB, inflammation, and oxidative stress that may impact maternal metabolism and/or placental function. SDB is common in pregnancy and affects fetal growth and development. Given that SDB has significant potential to adversely influence the intrauterine metabolic environment, larger, prospective studies in humans are urgently needed to fully elucidate the effects of this exposure on offspring metabolic risk.

Objectively assessed sleep-disordered breathing during pregnancy and infant birthweight

BACKGROUND

Sleep-disordered breathing (SDB) in pregnancy is associated with adverse maternal outcomes. The relationship between SDB and infant birthweight is unclear. This study's primary aim is to determine if objectively measured SDB in pregnancy is associated with infant birthweight.

METHODS

We measured SDB objectively in early (6-15 weeks' gestation) and mid (22-31 weeks' gestation) pregnancy in a large cohort of nulliparous women. SDB was defined as an Apnea-Hypopnea Index ≥5 and in secondary analyses we also examined measures of nocturnal hypoxemia. We used a modified Poisson regression approach to estimate relative risks (RR) of large-for-gestational-age (LGA: >90th percentile for gestational age) and small-for-gestational-age (SGA: <10th percentile for gestational age) birthweights.

RESULTS

The prevalence of early-pregnancy SDB was nearly 4%. The incidence of mid-pregnancy SDB was nearly 6.0%. The prevalence of LGA and SGA was 7.4% and 11.9%, respectively. Early-pregnancy SDB was associated with a higher risk of LGA in unadjusted models (RR 2.2, 95% CI 1.3-3.5) but not BMI-adjusted models (aRR 1.0, 95% CI 0.6-1.8). Mid-pregnancy SDB was not associated with SGA or LGA. Mid-pregnancy nocturnal hypoxemia (% of sleep time <90% oxygen saturation) and increasing nocturnal hypoxemia from early to mid-pregnancy were associated with a higher risk of LGA in BMI-adjusted models. SDB and nocturnal hypoxemia were not associated with SGA.

CONCLUSIONS

SDB in pregnancy was not associated with an increased risk of LGA or SGA birthweight, independent of BMI. Some measures nocturnal hypoxemia were associated with an increase in LGA risk, independent of BMI. ClinicalTrials.gov Registration number NCT02231398.

Sleep-Disordered Breathing and Pregnancy-Related Cardiovascular Disease

Sleep-disordered breathing (SDB) is a serious medical condition characterized by intermittent episodes of airflow limitation, intermittent hypoxia, and sleep disturbance triggering a pattern of autonomic dysfunction associated with hypertension, diabetes, and other adverse health conditions. SDB incidence is two to three times higher during pregnancy and is associated with an increased risk of cardiometabolic complications, including pre-eclampsia and gestational diabetes. Treatments to protect breathing during sleep are available, pointing to SDB as a potential therapeutic target to reduce maternal cardiometabolic morbidity. However, in clinical practice, the majority of SDB cases in pregnancy are undiagnosed, indicating a need to improve screening for SDB risk factors and referral for diagnostic testing. Furthermore, definitive clinical trials are needed to determine the extent to which SDB intervention reduces the risk of adverse cardiovascular and neonatal outcomes in pregnancy. This review article discusses an accumulation of research pointing to SDB as a prevalent risk factor for gestational cardiometabolic disease, as well as a potential therapeutic target to reduce cardiometabolic morbidity.

Obstructive sleep apnea is associated with adverse maternal outcomes using a United States multistate database cohort, 2007-2014

BACKGROUND

Obstructive sleep apnea affects approximately 11% of women of reproductive age, although it is often undetected and untreated. Previous studies suggest an association between obstructive sleep apnea and adverse maternal outcomes. Herein, we aim to better characterize the relationship between obstructive sleep apnea and maternal outcomes.

METHODS

Using the State Inpatient Databases, we performed a retrospective analysis of parturients ≥18 years old having inpatient deliveries in Florida, New York, California, Maryland, and Kentucky from 2007 to 2014. Outcomes included maternal pre-existing conditions, in-hospital mortality, maternal-fetal conditions and complications, and hospital length of stay >5 days.

RESULTS

Our cohort consisted of 6 911 916 parturients of whom 4326 (0.06%) had obstructive sleep apnea. Women with obstructive sleep apnea were more likely to present with pre-existing conditions, such as obesity and pre-pregnancy diabetes. After adjusting for patient- and hospital-level confounders in our multivariate analysis, obstructive sleep apnea status was associated with an increased odds of maternal-fetal conditions and complications, including pre-eclampsia (aOR 2.05, 95% CI 1.87 to 2.26), pulmonary edema (aOR 4.73, 95% CI 2.84 to 7.89), cesarean delivery (aOR 1.96, 95% CI 1.81 to 2.11), early onset delivery (aOR 1.28, 95% CI 1.17 to 1.40), and length of stay >5 days (aOR 2.42, 95% CI 2.21 to 2.65). Obstructive sleep apnea was not significantly associated with a higher risk of in-hospital mortality.

CONCLUSIONS

Pregnant women with obstructive sleep apnea have a significantly higher adjusted risk of adverse maternal outcomes compared with women without obstructive sleep apnea.

Prevalence of symptoms and risk of obstructive sleep apnea in Saudi pregnant women

BACKGROUND:

This case-control study aimed to assess the prevalence of symptoms and risk of obstructive sleep apnea (OSA) among Saudi pregnant women.

METHODS:

The study included consecutive Saudi pregnant women attending the antenatal service between July 2015 and December 2016. Pregnant women were compared with an age-matched group of nonpregnant women. OSA symptoms and risk were assessed using a validated Arabic version of the Berlin questionnaire (BQ).

RESULTS:

The study included 742 pregnant women and 742 age-matched nonpregnant women. At the time of the survey, 8.2% were in the first trimester; 33.4% in the second trimester; and 58.4%in third trimester. Snoring was reported by 14% of pregnant women, and 5% reported breathing pauses during sleep. Based on the BQ stratification for risk of OSA, 19.3% of pregnant women and 16.6% of the control group were at high risk for OSA. A comparison between the high OSA-risk and low OSA-risk pregnant women revealed that the pregnant women in high risk group were older (30.9 ± 5.9 years vs. 29 ± 5.4 years, P = 0.001), had a higher body mass index (BMI) (34.3 ± 5.2 kg/m² vs. 28.7 ± 5.8 kg/m², P < 0.001), and higher parity (1.9 ± 2 vs. 1.5 ± 1.7, P = 0.020). A multivariate logistic regression analysis revealed the following independent variables, BMI (odds ratio [OR] 1.173 [95% confidence interval [CI] 1.129–1.219],P < 0.001), pregnancy-induced hypertension (OR 7.85 [95% CI 1.691–36.447], P = 0.013), and the presence of restless legs syndrome (OR 2.209 [95% CI 1.332–3.279],P < 0.001).

CONCLUSIONS:

OSA symptoms and risk were relatively common among Saudi pregnant women. Increasing the awareness among physicians about this association is essential to improve early detection of the disorder.

Exploring Fetal Sex as a Risk Factor for Sleep Disordered Breathing and Its Complications in Pregnancy

Sleep disordered breathing (SDB) is a common, yet under-recognized and undertreated condition in pregnancy. Sleep disordered breathing is associated with pregnancy complications including preeclampsia, gestational diabetes, preterm birth, as well as severe maternal morbidity and mortality. The identification of risk factors for SDB in pregnancy may improve screening, diagnosis, and treatment of SDB prior to the onset of pregnancy complications. The goal of this study was to determine whether fetal sex increases risk of SDB in pregnancy. A cohort of singleton (N = 991) pregnant women were recruited within 24 to 48 hours of delivery and answered questions regarding SDB symptoms by questionnaire. Women who reported frequent loud snoring at least 3 times a week were considered to have SDB. Hospital records were reviewed to extract information on fetal sex and pregnancy complications including preeclampsia, pregnancy-induced hypertension, gestational diabetes, preterm delivery, and low birth weight. Women carrying male fetuses were significantly more likely to have SDB (β = .37, P = .01, OR: 1.45 [95% CI: 1.09–1.94]). Fetal sex was associated with increased risk of hypertensive disorders of pregnancy (defined as preeclampsia and/or pregnancy-induced hypertension) among women with SDB in pregnancy (β = .41, P = .02, OR: 1.51[95%CI:1.08–2.11]).Fetal sex did not increase risk of preterm birth, low birth weight, or gestational diabetes among women with SDB in pregnancy. Women carrying male fetuses were approximately 1.5 times more likely to report SDB in pregnancy compared to women carrying female fetuses, and women with pregnancy-onset SDB carrying male fetuses were 1.5 times more likely to have hypertensive disorders of pregnancy compared to women with SDB carrying female fetuses. Confirmation of fetal sex as a risk factor may, with other risk factors, play a role in identifying women at highest risk of SDB complications in pregnancy.

Sex- and Region-Specific Differences in the Transcriptomes of Rat Microglia from the Brainstem and Cervical Spinal Cord

The neural control system underlying breathing is sexually dimorphic with males being more vulnerable to dysfunction. Microglia also display sex differences, and their role in the architecture of brainstem respiratory rhythm circuitry and modulation of cervical spinal cord respiratory plasticity is becoming better appreciated. To further understand the molecular underpinnings of these sex differences, we performed RNA sequencing of immunomagnetically isolated microglia from brainstem and cervical spinal cord of adult male and female rats. We used various bioinformatics tools (Gene Ontology, Kyoto Encyclopedia of Genes and Genomes, Reactome, STRING, MAGICTRICKS) to functionally categorize identified gene sets, as well as to pinpoint common transcriptional gene drivers that may be responsible for the observed transcriptomic differences. We found few sex differences in the microglial transcriptomes derived from the brainstem, but several hundred genes were differentially expressed by sex in cervical spinal microglia. Comparing brainstem and spinal microglia within and between sexes, we found that the major factor guiding transcriptomic differences was central nervous system (CNS) location rather than sex. We further identified key transcriptional drivers that may be responsible for the transcriptomic differences observed between sexes and CNS regions; enhancer of zeste homolog 2 emerged as the predominant driver of the differentially downregulated genes. We suggest that functional gene alterations identified in metabolism, transcription, and intercellular communication underlie critical microglial heterogeneity and sex differences in CNS regions that contribute to respiratory disorders categorized by dysfunction in neural control. These data will also serve as an important resource data base to advance our understanding of innate immune cell contributions to sex differences and the field of respiratory neural control. SIGNIFICANCE STATEMENT: The contributions of central nervous system (CNS) innate immune cells to sexually dimorphic differences in the neural circuitry controlling breathing are poorly understood. We identify key transcriptomic differences, and their transcriptional drivers, in microglia derived from the brainstem and the C3-C6 cervical spinal cord of healthy adult male and female rats. Gene alterations identified in metabolism, gene transcription, and intercellular communication likely underlie critical microglial heterogeneity and sex differences in these key CNS regions that contribute to the neural control of breathing.

Sleep position and breathing in late pregnancy and perinatal outcomes

STUDY OBJECTIVES

Body position during sleep has been related to breathing in adults with obstructive sleep apnea (OSA). While sleep-disordered breathing is common, little information is available on the relation between sleep position and maternal breathing in pregnancy. We examined associations between the supine position, maternal breathing, and perinatal outcomes.

METHODS

Women with a singleton, uncomplicated pregnancy were recruited and underwent an ambulatory overnight sleep study between 33 to 36 weeks using the Watch-PAT device. Their medical records were also reviewed.

RESULTS

A total of 148 pregnant women were recruited (mean age: 33 ± 4 years; mean body mass index: 27.6 ± 4.0 kg/m²). They spent approximately one-half of their sleeping time in a supine position. The group's mean apnea-hypopnea index (AHI) was 3.6 events/h in the supine position and 2.9, 2.6, and 2.1 events/h for the prone, right, and left positions, respectively. Median AHI and oxygen desaturation index were higher and SpO₂ nadir was lower in the supine versus nonsupine position (P < .0001, P < .0001, and P = .006, respectively). Peripheral oxygen saturation nadir was associated with the percentage of time spent sleeping in the supine position (P = .02). No correlations were found between supine sleep position and perinatal outcomes. There were no differences in the distributions of body positions between women with and those without OSA.

CONCLUSIONS

Women in the third trimester of pregnancy with or without OSA spent large proportions of sleeping time in a supine position. Supine position was associated with more respiratory events and more and deeper oxygen desaturation events. They were not associated with perinatal outcomes.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Fetal Outcome of Sleep Disordered Breathing During Pregnancy; URL: https://clinicaltrials.gov/ct2/show/NCT00931099; Identifier: NCT00931099.

The association between allergic rhinitis and sleep: A systematic review and meta-analysis of observational studies

This systematic review and meta-analysis examines the associations of allergic rhinitis with sleep duration and sleep impairment. Observational studies published before August 2019 were obtained through English language literature searches in the PubMed, Embase, and CINAHL databases. Mean differences and odds ratios with 95% confidence intervals were extracted and used for meta-analysis. Heterogeneity was confirmed by the I2-heterogeneity test. Subgroup analysis was conducted to evaluate the influence of study design. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to determine the level of evidence. In total, 2544 records were identified through database searches; 914 duplicate records were excluded, 1452 records were removed after screening of titles and abstracts, 151 records were excluded after full-text screening, and 27 articles were included in the final meta-analyses. A total of 240,706,026 patients (19,444,043 with allergic rhinitis) were considered. No significant difference in sleep duration between the allergic rhinitis and the control groups was found. Patients with allergic rhinitis presented with significantly higher sleep quality scores, sleep disturbances scores, and sleep latency scores; more frequent use of sleep medications; and lower sleep efficiency as measured by the Pittsburgh Sleep Quality Index and polysomnography. Meta-analyses for adjusted odds ratios showed that allergic rhinitis was also associated with higher risks of nocturnal dysfunctions, including insomnia, nocturnal enuresis, restless sleep, sleep-disordered breathing, obstructive sleep apnea, and snoring. Meta-analysis for adjusted odds ratio also showed that allergic rhinitis was associated with daytime dysfunction, including difficulty waking up, daytime sleepiness, morning headache, and the use of sleep medications. The overall quality of evidence ranged from low to very low, indicating that caution is required when interpreting these results. This study demonstrates that there is a significant association of AR with sleep characteristics.

Evaluation of Nocturnal Respiratory Complaints in Pregnant Women

Snoring during pregnancy increases the risk of low Apgar score and low birth weight of newborns. Snoring women are twice as likely to be diagnosed as having preeclampsia when compared to non-snoring ones. Snoring may also be linked to, albeit it is not a prerequisite for, apneic events at sleep. The aim of this survey-type study was to evaluate the occurrence and severity of nocturnal respiratory complaints in a group of 312 pregnant women. Problems associated with snoring and other nasopharyngeal symptoms were reported by 60% of women. Complaints were more frequent in patients with a higher body mass index. The symptoms were significantly more frequent in the group of snorers. The results of this study suggest a pattern of basic features in pregnancy, such as snoring, overweight, and upper airway symptoms, which all ought to direct attention of care givers to the diagnostics of sleep-related breathing disorders. The early diagnosis would enable to undertake the measures to prevent preterm labor and to avoid postpartum complications in both mother and newborn.

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.

Intermittent hypoxia impairs uterine artery function in pregnant mice

KEY POINTS

Obstructive sleep apnoea (OSA) is a chronic condition characterized by intermittent hypoxia that induces oxidative stress and inflammation leading to cardiovascular disease. Women can develop OSA during late pregnancy, which is associated with adverse maternal and fetal outcomes. However, the effects of OSA throughout pregnancy on fetoplacental outcomes are unknown. Using a mouse model of intermittent hypoxia, we evaluated main uterine artery function, spiral artery remodelling, circulating angiogenic and anti-angiogenic factors, and placental hypoxia and oxidative stress at gestational day 14.5 in pregnant mice. Gestational intermittent hypoxia increased placental weight but decreased fetal weight, impaired uterine artery function, increased circulating angiogenic and anti-angiogenic factors, and induced placental hypoxia and oxidative stress, but had no impact on spiral artery remodelling. Our results suggest that pregnant women experiencing OSA during pregnancy could be at risk of maternal and fetal complications.

ABSTRACT

Obstructive sleep apnoea (OSA) is characterized by chronic intermittent hypoxia (IH) and is associated with increased inflammation, oxidative stress and endothelial dysfunction. OSA is a common sleep disorder and remains under-diagnosed; it can increase the risk of adverse maternal and fetal outcomes in pregnant women. We investigated the effects of gestational IH (GIH) on uterine artery function, spiral artery remodelling and placental circulating angiogenic and anti-angiogenic factors in pregnant female mice. WT C57BL/6 mice (8 weeks) were exposed to either GIH ( F I O 2 12%) or intermittent air ( F I O 2 21%) for 14.5 days of gestation. Exposure to GIH reduced fetal weight but increased placental weight. GIH dams had higher plasma levels of oxidative stress (8-isoprostane) and inflammatory markers (tumour necrosis factor-α). GIH significantly reduced uterine artery function as indicated by reduced endothelium-dependent vasodilatation and enhanced vasoconstriction. Plasma levels of placental angiogenic and anti-angiogenic markers (soluble fms-like tyrosine kinase-1, soluble endoglin, angiogenic placental growth factor-2 and vascular endothelial growth factor) were higher in pregnant mice exposed to GIH. There was no evidence of impaired spiral artery remodelling based on immunostaining with α-smooth muscle actin and cytokeratin-7, and also by measurements of lumen area. Immunostaining for markers of hypoxia (pimonidazole) and oxidative stress (4-hydroxynonenal) were higher in mice exposed to GIH. Our data show that GIH adversely affects uterine vascular function and may be a mechanism by which gestational OSA leads to adverse maternal and fetal outcomes.

Pathophysiological changes associated with sleep disordered breathing and supine sleep position in pregnancy

Sleep is a complex and active physiological process that if disrupted, can result in adverse outcomes both within and outside of pregnancy. Sleep disordered breathing (SDB) occurs in 10-32% of pregnancies. Substantial physiological changes occur during pregnancy that impact on maternal sleep, which typically deteriorates with advancing gestation. Pregnancy challenges maternal homeostatic regulation of many systems which effect maternal sleep, including the respiratory, cardiovascular, endocrine, and immune systems. SDB can result from varying degrees of airway compromise and potentially cause systemic hypoxia. The hypoxia may be acute, intermittent or chronic in nature with complications dependant on the duration and the gestation at which the insult occurs. It is unlikely that this effect is mediated by a singular mechanistic pathway but results from a complex cascade of events across multiple maternal organ systems. Regardless of the etiology, both SDB and supine sleep position are associated with a variety of obstetric and perinatal complications including, pre-eclampsia/eclampsia, gestational diabetes mellitus, cardiomyopathy, heart failure, fetal growth restriction, poor neonatal condition at birth, stillbirth and neuro-psychiatric problems in offspring. Both maternal sleep position and sleep disordered breathing are potentially modifiable or treatable factors that if addressed have the potential to improve maternal and fetal outcomes. This narrative review summarizes the maternal and placental pathophysiological aberrations associated with sleep disordered breathing and supine sleep position in pregnancy.

Pregnant pause: should we screen for sleep disordered breathing in pregnancy?

Physiological and hormonal changes in pregnancy can contribute towards sleep disordered breathing in pregnant women (SDBP). When present, SDBP increases the risk of several adverse maternal and fetal outcomes independent of factors such as age, weight and pre-existing maternal comorbidities. SDBP is underdiagnosed and may be hard to recognise because the presentation can be difficult to differentiate from normal pregnancy and the severity may change over the course of gestation. Timely intervention seems likely to help reduce adverse outcomes, but the relative benefits of intervention are still unclear. The definition of what constitutes a sleep-related breathing “disorder” in pregnancy may be different to the general population and so traditional thresholds for intervention may not be relevant in pregnancy. Any modifications to the disease definition in this group, or implementation of more intensive screening, may result in overdiagnosis. Further research is needed to help clinicians evaluate the balance of benefits and harms in this process. Until this is clearer there is a strong imperative for shared decision making in screening and treatment decisions, and screening programmes should be monitored to assess whether improved outcomes can be achieved at the healthcare system level.

Untreated sleep disordered breathing in pregnancy poses risks to maternal and fetal wellbeing, but thresholds for and effectiveness of intervention are unclear. Clinicians should use shared decision making for screening and treatment decisions.http://ow.ly/N0oN30noWnx

Sleep-Disordered Breathing in Pregnancy

Sleep-disordered breathing (SDB) in pregnancy can present as snoring and/or obstructive sleep apnea (OSA), and the prevalence is increasing due to the increase in maternal obesity. Pregnant women often present with fatigue and daytime sleepiness rather than the classic symptoms. Habitual snoring, older age, chronic hypertension, and high prepregnancy body mass index are reliable indicators of increased risk for SDB and should trigger further testing. The gold standard for diagnosis of OSA is an overnight laboratory polysomnography. Although there are no studies linking SDB to poor fetal outcomes, fetal well-being remains paramount throughout the course of pregnancy.

Maternal Weight, Snoring, and Hypertension: Potential Pathways of Associations

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are linked to excessive maternal weight and frequent snoring. However, pathways between maternal excessive weight, pregnancy-onset snoring, and HDP are only partially estimated. We examined and quantified the total and direct associations between excessive maternal weight and incident HDP and their indirect pathway through pregnancy-onset snoring.

METHODS

Third trimester pregnant women enrolled from prenatal clinics of a large tertiary medical center. Sleep data were collected through a questionnaire. Demographic and pregnancy information and first trimester maternal weight were abstracted from medical charts. After exclusion of women with prepregnancy hypertension and/or chronic snoring, causal mediation analysis was used to estimate the total and direct association between maternal weight and incident HDP and their indirect association through pregnancy-onset snoring. The proportion of the mediated association through pregnancy-onset snoring from the total association of maternal weight and HDP was also quantified.

RESULTS

After excluding those with chronic hypertension and/or snoring, the final sample included 1,333 pregnant women. In adjusted analysis, excessive maternal weight was directly associated with incident HDP; odds ratio (OR) = 1.87 (95% confidence interval (CI) 1.30, 2.70). Pregnancy-onset snoring significantly mediated the association between maternal weight and incident HDP; OR = 1.08 (95% CI 1.01, 1.17). The mediated pathway accounted for 15% of the total association between maternal weight and incident HDP.

CONCLUSIONS

Pregnancy-onset snoring mediates the association between maternal weight and incident HDP in women without prepregnancy snoring or hypertension. These findings demonstrate the relative contributions of excessive maternal weight and pregnancy-onset snoring to incident HDP.

Snoring and Blood Pressure in Third-Trimester Normotensive Pregnant Women

PURPOSE

To examine the association between snoring, sleep quality, quantity, and blood pressure in third-trimester normotensive pregnant women.

DESIGN

This study was a cross-sectional analysis of two cohorts of healthy pregnant women recruited from a prenatal clinic in a medical center in Northern Taiwan.

METHODS

A total of 322 women reported sociodemographic and health characteristics in a structured interview and wore a wrist actigraph on their nondominant wrist for 7 consecutive days to assess objective sleep patterns. The women's resting blood pressures were measured while seated in the clinic by trained personnel using an electronic sphygmomanometer.

FINDINGS

One hundred thirty-three (41.3%) women reported snoring. Ninety-three women (28.9%) had <6 hr of nighttime sleep, with only 95 (29.5%) women averaging 7 or more hours of nighttime sleep. In the univariate analyses, snoring was positively associated with systolic and diastolic blood pressure as well as mean arterial pressure levels (p < .05). In the multivariate analyses, snoring remained as a significant predictor of higher diastolic blood pressure (β = 2.07, p < .05) and mean arterial pressure levels (β = 2.00, p < .05), after adjustment for age, parity, gestational age, body mass index before pregnancy, and sleep quantity and quality by actigraphy.

CONCLUSIONS

Snoring is a highly prevalent condition experienced by healthy third-trimester pregnant women and is associated with elevated blood pressure.

CLINICAL RELEVANCE

Clinical assessment and screening of snoring are of utmost importance in obstetric nursing practice to potentially prevent or reduce the associated adverse cardiovascular consequences in women during pregnancy.

Association between Sleep-Disordered Breathing during Pregnancy and Maternal and Fetal Outcomes: An Updated Systematic Review and Meta-Analysis

Background

Due to the high prevalence in pregnant women and potential association with pregnancy complications or perinatal outcomes, sleep-disordered breathing (SDB) has become an increasing concern.

Methods

Pubmed and Embase were retrieved from inception until 2017 to conduct a meta-analysis to explore the association of SDB and several outcomes during gestation. A stratified analysis differentiated by the type of SDB [snoring alone/obstructive sleep apnea (OSA)] was also performed. Pooled odds ratios were produced for binary outcomes. Weighted mean differences were also produced for continuous outcomes. Sensitivity analysis was performed to identify the impact of individual studies on summary results and estimation of publication bias was performed by funnel plot.

Results

35 studies with a total of 56,751,837 subjects were included. SDB during pregnancy was associated with a significantly increased risk of gestational diabetes mellitus (GDM), pregnancy-induced hypertension (PIH), and preeclampsia (PEC), but not significantly associated with fetal maternal outcomes, namely APGAR score and birth weight. Moreover, OSA was linked with an increasing risk of GDM, PIH, PEC and preterm birth while snoring appeared to increase the risk of GDM, PIH, and PEC.

Conclusion

The finding provided potential evidence for association between SDB and adverse perinatal outcomes. SDB increased the risk of some pregnancy complications while its influence to fetal outcomes was not clear.

Peripartum Management of Obstructive Sleep Apnea

The prevalence of obstructive sleep apnea is unknown during pregnancy, but the syndrome is likely underdiagnosed and rising in frequency along with the obesity epidemic. Obstructive sleep apnea is associated with adverse outcomes, including hypertensive disorders of pregnancy, gestational diabetes, preterm, and cesarean delivery. Obese pregnant women should be screened and referred to a sleep medicine specialist for evaluation. Continuous positive airway pressure is the treatment of choice with demonstrated safety and compliance in pregnancy. Early anesthesia consultation allows for preparation and implementation of a peripartum plan that includes early labor analgesia, avoidance of respiratory depressants, and closer monitoring of oxygenation.

Obesity in Pregnancy: Optimizing Outcomes for Mom and Baby

Obesity is common in women of childbearing age, and management of this population around the time of pregnancy involves specific challenges. Weight and medical comorbidities should be optimized both before and during pregnancy. During pregnancy, gestational weight gain should be limited, comorbidities should be appropriately screened for and managed, and fetal health should be monitored. Consideration should be given to the optimal timing of delivery and to reducing surgical and anesthetic complications. In the postpartum period, breastfeeding and weight loss should be promoted. Maternal obesity is associated with adverse metabolic effects in offspring, promoting an intergenerational cycle of obesity.

The role of sleep duration and sleep disordered breathing in gestational diabetes mellitus

Many women experience sleep problems during pregnancy. This includes difficulty initiating and maintaining sleep due to physiologic changes that occur as pregnancy progresses, as well as increased symptoms of sleep-disordered breathing (SDB). Growing evidence indicates that sleep deficiency alters glucose metabolism and increases risk of diabetes. Poor sleep may exacerbate the progressive increase in insulin resistance that normally occurs during pregnancy, thus contributing to the development of maternal hyperglycemia. Here, we critically review evidence that exposure to short sleep duration or SDB during pregnancy is associated with gestational diabetes mellitus (GDM). Several studies have found that the frequency of GDM is higher in women exposed to short sleep compared with longer sleep durations. Despite mixed evidence regarding whether symptoms of SDB (e.g., frequent snoring) are associated with GDM after adjusting for BMI or obesity, it has been shown that clinically-diagnosed SDB is prospectively associated with GDM. There are multiple mechanisms that may link sleep deprivation and SDB with insulin resistance, including increased levels of oxidative stress, inflammation, sympathetic activity, and cortisol. Despite emerging evidence that sleep deficiency and SDB are associated with increased risk of GDM, it has yet to be demonstrated that improving sleep in pregnant women (e.g., by extending sleep duration or treating SDB) protects against the development of hyperglycemia. If a causal relationship can be established, behavioral therapies for improving sleep can potentially be used to reduce the risk and burden of GDM.

Sleep disruption and duration in late pregnancy is associated with excess gestational weight gain among overweight and obese women

BACKGROUND

Poor sleep during pregnancy has been associated with poorer birth outcomes. High body mass index (BMI) is often associated with poor sleep, but little is known about the relationship between gestational weight gain and sleep in late pregnancy. The purpose of this study was to evaluate the relationships of both gestational weight gain and pre-pregnancy BMI to objective and subjective measures of sleep during late pregnancy.

METHODS

Pregnant women (n=128) were recruited from prenatal clinics and childbirth classes primarily serving low-income women. Their sleep (disruption and duration) was objectively assessed in their last month of pregnancy with 72 hours of wrist actigraphy monitoring. Their perceived sleep quality was assessed with the Pittsburgh Sleep Quality Index. Pre-pregnancy and late pregnancy height and weight were assessed by self-report and used to calculate BMI and gestational weight gain, which were then grouped into standardized categories.

RESULTS

Mean Pittsburgh Sleep Quality Index score was 6.8 ± 3.1 (range 2-16). Sixty percent had excess gestational weight gain and it was associated with poorer perceived sleep quality, but was unrelated to objective measures of sleep duration and disruption. Pre-pregnancy BMI was unrelated to all sleep parameters. However, analyses of the interaction of pre-pregnancy BMI and gestational weight gain indicated that excess weight gain was associated with shorter sleep duration and more sleep disruption, but only among women who were overweight before pregnancy.

CONCLUSION

Pregnancy is an opportunity to promote long-term women's health with a better understanding of the relationship between weight management and healthy sleep habits.