Sleep-disordered Breathing in Pregnancy
Section snippets
Factors predisposing to SDB in pregnancy
During pregnancy, airway mucosa undergoes changes that lead to edema and friability.4 These changes are believed to be related to increased plasma volume and capillary engorgement, as well as the higher levels of estrogens. These changes may be accentuated by a mild respiratory tract infection, fluid overload, preeclampsia, and other factors. In some patients, changes in the nasal mucosa lead to the development of gestational rhinitis, which consists of symptomatic nasal congestion that
Factors protecting against SDB in pregnancy
Factors that may protect against the development of SDB in pregnancy include increased minute ventilation,15 as well as a preference for the lateral sleeping position in late gestation16 and decreases in rapid eye movement (REM) sleep.17
Progesterone stimulates the ventilatory drive and increases electromyographic activity of the upper airway dilator muscle.18 Progesterone’s stimulating properties enhance the responsiveness of the upper airway dilator muscles to chemical stimuli during sleep.19,
Epidemiology
The prevalence of SDB in pregnancy has not yet been studied but a few studies report the incidence of symptoms of SDB in this population. As a general rule, women tend to under-report snoring. Many studies suggest that snoring occurs in 14% to 45% of pregnant women1, 2, 27 as opposed to 4% of premenopausal, nonpregnant women. Pregnant women are more likely to have a bed partner, and therefore could possibly be more likely to report awareness of their snoring. In a large epidemiologic study of
Gestational Hypertensive Disorders
Associations between SDB symptoms and gestational hypertensive disorders have been shown in multiple studies1, 2, 3, 27, 30 after correction for other risk factors (Table 1). In addition, polysomnographically diagnosed SDB was found significantly more frequently in women with gestational hypertensive disorders.31 Another study showed a significantly higher rate of preeclampsia in women with OSA compared with normal weight pregnant controls but not compared with pregnant obese controls.32
Preterm Birth
Preterm labor is one of the most common complications of pregnancy, potentially resulting in preterm delivery. Preterm birth is defined as birth occurring before 37 weeks’ gestation and occurs in about 12% of deliveries in the United States. Prematurity is a significant cause of morbidity and mortality. Preterm birth may result from conditions such as preterm premature rupture of membranes, preterm labor, infection, or may be induced for fetal or maternal well-being. Preliminary data show that
Clinical Risk Assessment
Several clinical diagnostic tools have been developed for the evaluation of SDB. For instance, the Berlin Questionnaire is a 10-item survey that was developed for the primary care setting and consists of 3 categories related to the risk of having sleep apnea.61 Other questionnaires have been developed for the preoperative population.62 Many of these tools include weight in risk assessment. Pregnancy is associated with weight gain that varies from an increase in plasma volume and fat deposition
Treatment
Just like the nonpregnant population, the diagnosis of OSA should be firmly established and its severity determined before making further decisions regarding management. Once the diagnosis is established, patients should be educated about risk factors, natural history, and consequences of OSA. Although outcome studies for pregnancy-associated complications are mainly based on studies of symptoms of SDB rather than polysomnography-confirmed SDB, it is possible that these outcomes are at least as
Screening for SDB
It is reasonable to screen pregnant patients with gestational hypertensive disorders for the presence of symptoms suggestive of SDB. However, given the lack of validated clinical tools and the poor positive predictive value of existing questionnaires in pregnancy,53, 55 screening may not yet prove to be cost-effective.
Summary
Pregnant women may be predisposed to the development of SDB given the physiologic changes of pregnancy. Evidence suggests an association of symptoms of SDB in pregnancy and adverse outcomes. Validation of clinical tools is needed in pregnancy given that current tools do not have an adequate predictive power. Treatment of SDB with CPAP in pregnancy is efficacious, with positive hemodynamic effects in women with preeclampsia. Pressure requirements may increase slightly during the course of the
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Cited by (81)
Sleep Disorders and Gestational Diabetes Mellitus
2020, Neurological Modulation of Sleep: Mechanisms and Function of Sleep HealthA review of the associations between obstructive sleep apnea and hypertensive disorders of pregnancy and possible mechanisms of disease
2018, Sleep Medicine ReviewsCitation Excerpt :Some of these airway changes are more pronounced in women who develop preeclampsia; the association between OSA and preeclampsia may be bidirectional [48,49]. However, other pregnancy-related factors may be protective, such as preference for the lateral sleep position and increased respiratory rate due to hormonal changes [50,51]. The health consequences of the timing of the onset of OSA, either prior to or during pregnancy, are not well elucidated.
Snoring and markers of fetal and placental wellbeing
2018, Clinica Chimica ActaSleep in Women Across the Life Span
2018, Chest