High prevalence of obstructive sleep apnea in pregnant women with class III obesity: a prospective cohort study

A Relation between Obstructive Sleep Apnea in Pregnancy and Delivering Small for Gestational Age Infant-A Systematic Review

Obstructive sleep apnea (OSA) during pregnancy can negatively affect both the mother and the baby. Our main goal is to show whether there is an association between OSA during pregnancy and delivering small for gestational age (SGA) infants. This systematic review was conducted according to the PRISMA 2020 statement using three databases: MEDLINE via PubMed, Scopus, and Cochrane Library. All databases were last accessed on 1 June 2023. The implemented systematic literature search identified 744 articles. After excluding reviews, meta-analyses, book chapters, case reports, and letters, 47 studies were analyzed, 18 of which finally met the inclusion criteria. The included studies mainly indicate that OSA during pregnancy may not significantly impact SGA, but some of them have shown the existence of this relation. Nevertheless, it is recommended that all pregnant women should be screened for symptoms of OSA and that sleep tests should be performed on those who show signs of it. Detecting and treating OSA early in pregnancy can help reduce the condition's negative effects. However, more extensive studies are still needed to gather clear evidence on the impact of an OSA diagnosis on mothers and babies.

Treatment of obstructive sleep apnea in high risk pregnancy: a multicenter randomized controlled trial

BACKGROUND

Obstructive sleep apnea (OSA) during pregnancy is a risk factor for preeclampsia possibly through a link to placental physiology. This study evaluates the efficacy of continuous positive airway pressure (CPAP) on the modulation of blood pressure and the reduction in preeclampsia in women with high-risk pregnancy and OSA.

METHODS

A multicenter open-label, randomized controlled trial comparing CPAP treatment versus usual antenatal care was conducted in three academic hospitals in Bangkok, Thailand. Participants included singleton pregnant women aged older than 18 years with any high-risk condition (i.e., chronic hypertension, obesity, history of preeclampsia or gestational diabetes in the previous pregnancy, or diabetes), and OSA (respiratory disturbance index 5-29.99 events/hour by polysomnography), who presented either in the first trimester (gestational age, GA 0-16 weeks) or subsequently developed OSA during the 2nd trimester (GA 24-28 weeks). The primary endpoint was blood pressure during antenatal care. Secondary endpoints included the incidence of preeclampsia. An intention-to-treat analysis was performed with additional per-protocol and counterfactual analyses for handling of nonadherence.

RESULTS

Of 340 participants, 96.5% were recruited during the first trimester. Thirty participants were later excluded leaving 153 and 157 participants in the CPAP and usual-care groups for the modified-intention-to-treat analysis. CPAP adherence rate was 32.7% with average use of 2.5 h/night. Overall, CPAP treatment significantly lowered diastolic blood pressure (DBP) by - 2.2 mmHg [95% CI (- 3.9, - 0.4), p = 0.014], representing approximately - 0.5 mmHg per hour of CPAP use [95%CI (- 0.89, - 0.10), p = 0.013]. CPAP treatment also altered the blood pressure trajectory by continuously lowering DBP throughout pregnancy with mean differences (95% CI) of - 3.09 (- 5.34, - 0.93), - 3.49 (- 5.67, - 1.31) and - 3.03 (- 5.20, - 0.85) mmHg at GA 18-20, 24-28, and 32-34 weeks, respectively compared to 0-16 weeks. Preeclampsia rate was 13.1% (20/153 participants) in the CPAP and 22.3% (35/157 participants) in the usual-care group with a risk difference (95% CI) of - 9% (- 18%, - 1%, p-value = 0.032) and a number-needed-to-treat (95% CI) of 11 (1, 21).

CONCLUSIONS

CPAP treatment in women with even mild-to-moderate OSA and high-risk pregnancy demonstrated reductions in both DBP and the incidence of preeclampsia. CPAP treatment also demonstrated a sustained reduction in DBP throughout gestation. Trial registration ClinicalTrial.GovNCT03356106, retrospectively registered November 29, 2017.

Continuous positive airway pressure treatment of obstructive sleep apnea and hypertensive complications in high-risk pregnancy

PURPOSE

To evaluate whether or not continuous positive airway pressure (CPAP) treatment in pregnancies complicated by obstructive sleep apnea (OSA) is associated with a decrease in hypertensive disorders of pregnancy.

METHODS

This was a retrospective cohort study of perinatal outcomes in women who underwent objective OSA testing and treatment as part of routine clinical care during pregnancy. Where diagnostic criteria for OSA were reached (respiratory event index (REI) ≥ 5 events per hour), patients were offered CPAP therapy. Obstetrical outcomes were compared between the control group (no OSA), the group with untreated OSA (OSA diagnosed, not CPAP compliant), and the group with treated OSA (OSA diagnosed and CPAP compliant), with CPAP compliance defined as CPAP use ≥ 4 h, 70% of the time or greater. A composite hypertension outcome combined diagnoses of gestational hypertension (gHTN) and preeclampsia (PreE) of any severity.

RESULTS

The study comprised outcomes from 177 completed pregnancies. Our cohort was characterized by obesity, with average body mass indices > 35 kg/m2, and average maternal age > 30 years old. CPAP was initiated at an average gestational age of 23 weeks (12.1-35.3 weeks), and average CPAP use was 5.9 h (4-8.5 h). The composite hypertension outcome occurred in 43% of those without OSA (N = 77), 64% of those with untreated OSA (N = 77), and 57% of those with treated OSA, compliant with CPAP (N = 23) (p = 0.034).

CONCLUSION

Real-world data in this small study suggest that CPAP therapy may modulate the increased risk of hypertensive complications in pregnancies complicated by OSA.

Obstructive sleep apnea in pregnant women

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

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