Pregnancy and Sleep Apnea

Obstructive sleep apnea (OSA) during pregnancy presents significant potential risks to both the mother and her fetus. Symptoms of OSA in pregnant women should not be ignored, and it is important not to delay diagnosis or treatment.

There are four things that make OSA during pregnancy unique:

  • It affects not just one but two patients – the mother and the fetus. For this reason, it is recommended that a pregnant woman is screened for OSA during pregnancy and that questions about OSA-related symptoms be a part of prenatal checkups.
  • Pregnancy itself is often associated with symptoms that might mimic OSA, including sleep disturbance and daytime fatigue. Whenever in doubt, clinicians should perform a sleep study to confirm whether or not it is OSA that is contributing to the symptoms.
  • Sleep apnea can worsen as pregnancy progresses and changes in the condition can occur rapidly. OSA should always be diagnosed and treated promptly. The woman’s response to treatment should also be closely monitored. If frequent changes in CPAP settings are required, clinicians should consider whether auto-titrating positive airway pressure (APAP) devices would be more effective.
  • OSA may be temporary, and in those cases it should resolve upon delivery. Women diagnosed with OSA during pregnancy should be reevaluated during the postpartum period.

Sleep Disturbance during Pregnancy

A good night’s sleep can be fleeting during various stages of pregnancy. Many women indicate to their physicians that sleep quality generally deteriorates during the first trimester of pregnancy, improves transiently during the second trimester in some women, and is worst during the third trimester. Common causes of pregnancy-related sleep disturbance include breast tenderness, back pain, heartburn, nausea and vomiting, shortness of breath, and fetal movements.

Prevalence and severity of certain sleep disorders may also increase during pregnancy1 and can, in turn, contribute to poor sleep quality. In addition to OSA, these include snoring, restless legs syndrome, nocturia (frequent nighttime urination), and leg cramps. As a result of nighttime sleep disturbance, many women report taking more naps during the daytime.

OSA & Pregnancy

Studies2 indicate the prevalence of OSA can be as high as 15% during pregnancy, which is much higher in comparison to the non-gravid state. Even higher rates of OSA are found among pregnant women who are already obese3 prior to pregnancy, who gain significant weight during pregnancy, and those who snore.

New-onset OSA can develop during early pregnancy in up to 20% of high-risk women (i.e., those with BMI ≥ 30 kg/m2, chronic hypertension, pregestational diabetes, history of preeclampsia, and/or a twin gestation4).

Consequences from OSA during pregnancy to the mother can include preeclampsia, eclampsia, cardiomyopathy, pulmonary embolism and gestational diabetes. The fetus can suffer the consequences of intrauterine growth restriction. In addition, odds of in-hospital death are higher in women with OSA compared to those without OSA. All of these events are often exacerbated by comorbid obesity.

Nearly 30% of pregnant women experience a worsening of OSA during pregnancy. However, OSA is not commonly assessed during routine prenatal care. In one study5, although 32% of patients reported snoring, less than 3% of physicians and nurses asked their patients about snoring during a prenatal visit. The waters are further muddied by the fact that currently available subjective screening tools, such as the Berlin and STOP-BANG questionnaires, are poorly predictive of OSA during early pregnancy. Their usefulness, however, increases during the second or third trimesters.

Pregnancy-Induced Hypertension

Up to a third of women with gestational hypertension may have concurrent OSA6. In fact, OSA has been linked to the development of preeclampsia even after controlling for BMI, maternal age and diabetes7. Preeclampsia is characterized by hypertension, proteinuria, pedal edema and headaches.

Equally important, OSA is more common in pregnant women with hypertension compared to normotensive controls. Preeclamptic women tend to have more severe OSA with greater number of apnea-hypopnea events and worse nighttime oxygenation. Thus, it is important to screen hypertensive pregnant women for OSA.

Gestational Diabetes

OSA during pregnancy may impair glucose mechanism and result in the development of gestational diabetes (GDM), independent of obesity8. Pregnant women who have OSA may have more than a threefold increased risk of GDM9. More severe OSA in early pregnancy is associated with greater risk of GDM.

OSA is more prevalent in women with GDM than in those with normal glucose levels. Other factors that have been shown to be associated with higher glucose levels during pregnancy include presence of snoring, greater frequency of arousals from sleep, higher oxygen desaturation index (number of episodes of oxygen desaturation per hour of sleep), and duration of naps10.

Impaired Fetal Growth

Reduced fetal growth in late pregnancy has been described in women with OSA. Decreased fetal movements and a change in fetal movement patterns can complicate preeclamptic pregnancies. Substantially less fetal hiccups have also been reported. Fetal movements, including hiccups, are markers of fetal health. It is widely believed that only mature fetuses hiccup since this requires an adequately developed central nervous system.

In one study11, continuous positive airway pressure (CPAP) therapy increased the frequency of fetal movements and hiccups. Finally, OSA enhances the likelihood of preterm birth, cesarean delivery, and neonatal intensive care unit admission.

While OSA developed during pregnancy may improve or resolve after delivery, it is essential to reevaluate women who developed OSA during pregnancy in the postpartum period.

Teofilo L. Lee-Chiong Jr., MD is Chief Medical Liaison for Philips Respironics and a professor of medicine at National Jewish Health in Denver and at the University of Colorado School of Medicine.

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