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Obstructive sleep apnea in pregnancy is associated with adverse maternal outcomes: a national cohort
Abstract
Objective
Pregnancy and the obesity epidemic impacting women of reproductive age appear to predispose women to obstructive sleep apnea (OSA) in pregnancy. The aim of this study is to examine the association between OSA and adverse maternal outcomes in a national cohort.
Methods
The National Perinatal Information Center in the US was used to identify women with a delivery discharge diagnosis of OSA from 2010 to 2014. We used the International Classification of Diseases, ninth Revision to classify OSA diagnosis and maternal outcomes.
Measurements
The sample consisted of 1,577,632 gravidas with a rate of OSA of 0.12% (N = 1963). There was a significant association between OSA and preeclampsia (adjusted odds ratio (aOR) 2.22, 95% confidence interval (CI) 1.94–2.54), eclampsia (aOR 2.95, 1.08–8.02), and gestational diabetes (aOR 1.51, 1.34–1.72) after adjusting for a comprehensive list of covariates which includes maternal obesity. OSA status was also associated with a 2.5–3.5-fold increase in risk of severe complications such as cardiomyopathy, congestive heart failure, and hysterectomy. Length of hospital stay was significantly longer (5.1 + 5.6 vs 3.0 + 3.0 days, p < 0.001) and odds of an admission to an intensive care unit higher (aOR 2.74, 2.36–3.18) in women with OSA.
Conclusions
Compared to pregnant women without OSA, pregnant women with OSA have a significantly higher risk of pregnancy-specific complications such as gestational hypertensive conditions and gestational diabetes, and rare medical and surgical complications such as cardiomyopathy, pulmonary edema, congestive heart failure, and hysterectomy. OSA diagnosis was also associated with a longer hospital stay and significantly increased odds for admission to the intensive care unit.
... An association between eclampsia and OSA has been reported (96,122). The association between preeclampsia and OSA is well established with odds ratios (OR's) and adjusted OR's (aOR's) in the range of 1.6 to 3.5 (31,32,34,95,96,110,(122)(123)(124). ...
... An association between eclampsia and OSA has been reported (96,122). The association between preeclampsia and OSA is well established with odds ratios (OR's) and adjusted OR's (aOR's) in the range of 1.6 to 3.5 (31,32,34,95,96,110,(122)(123)(124). This has been confirmed with OSA occurring in early pregnancy or late pregnancy (91) and particularly in the moderate-to severe-OSA categories (35). ...
... An association between GDM and OSA is well-established (31,32,91,99,122) and remains significant when adjusted for BMI (36,55). More frequent and more severe OSA events are associated with GDM (35,129) and higher fasting glucose levels (35,102). ...
In this review, we provide a comprehensive overview of common sleep disorders during pregnancy, including their characterization, prevalence, risk factors, and possible contribution to maternal and fetal outcomes. We conducted a quasi-systematic literature search of the MEDLINE database and identified 744 studies from 1991 through 2021, inclusive, that met our inclusion criteria. We synthesized the existing literature on sleep disorders during pregnancy and highlighted controversies, research gaps, and needed clinical developments. Our review covers a range of sleep disorders, including insomnia, obstructive sleep apnea, restless legs syndrome, and circadian rhythm disorders. We discuss the prevalence of these disorders in pregnancy and their potential impact on maternal and fetal health outcomes. We also explore the relationship between sleep disorders, pre-pregnancy comorbidities such as obesity, and pregnancy-related conditions such as gestational diabetes mellitus and preeclampsia. In addition to summarizing the existing literature on sleep disorders during pregnancy, we also highlight opportunities for further research in this area. We suggest that future studies should strive to employ validated and objective measurement tools for sleep disorders and prioritize utilization of longitudinal methods with participant follow-up through postpartum, mid-life, menopause, and beyond. We also put forward investigation into the impact of circadian rhythm disruption on reproductive physiology and early pregnancy outcomes as an area of important work. Overall, our review provides valuable insights on sleep and reproduction and into common sleep disorders during pregnancy and their potential impact on maternal and fetal health outcomes.
... It has been previously established that pregnancy is associated with a higher prevalence of SDB and that SDB is associated with pregnancy-specific outcomes such as preeclampsia and gestational diabetes [65,66] severe maternal morbidity [65,66] and adverse fetal and neonatal outcomes [67][68][69]. Though reproductive hormones may contribute to the pathobiology of SDB in pregnancy, other pregnancy-specific physical and biological factors may also play a role [70,71]. ...
... It has been previously established that pregnancy is associated with a higher prevalence of SDB and that SDB is associated with pregnancy-specific outcomes such as preeclampsia and gestational diabetes [65,66] severe maternal morbidity [65,66] and adverse fetal and neonatal outcomes [67][68][69]. Though reproductive hormones may contribute to the pathobiology of SDB in pregnancy, other pregnancy-specific physical and biological factors may also play a role [70,71]. ...
Introduction:
Sleep disordered breathing (SDB) is a common condition, associated with multiple comorbidities including cardiovascular and metabolic disease. It has been previously established that SDB is more prevalent in men than women, shifting the literature's focus away from the latter population. As such, underdiagnosis, and thus undertreatment, of SDB in women exists.
Methods:
To establish the differences in prevalence, clinical presentation, and pathophysiology of SDB between the two sexes, a narrative review of the current literature was performed.
Results:
Rates of SDB are higher among men, likely driven by differences in symptom presentation between men and women, with women presenting with more "atypical" symptoms, and lack of sensitivity in SDB screening tools to detect SDB in women. In addition to the cardiovascular risks of SDB, women with SDB may have worse quality of life, higher prevalence of insomnia, and respiratory issues.
Discussion:
More research is needed to better define the unique pathophysiology and clinical presentation of SDB in women. In addition, an increased awareness among health care providers and the lay public of the SDB-specific sex and gender differences will serve to minimize disparities in identification and treatment of SDB in women.
... [3][4][5]15 In some patients, it has been reported that the supine sleep position is also associated with increased severity of sleep-disordered breathing (SDB), which includes snoring and obstructive sleep apnea. [17][18][19][20] Sleep-disordered breathing during gestation can increase the risk of a myriad of negative pregnancy outcomes, such as gestational diabetes, [22][23][24][25][26] gestational hypertension/preeclampsia, [21][22][23][24]26,27 preterm delivery 2,4,26,27 cesarean sections, 23,27 low birth weight, 24,27 small for gestational age (SGA), 27 and intensive care unit admissions. 22 In our study, 26 out of 300 women (8.7%) self-reported snoring, while 125 (41.7%) of them were not sure whether they snored or not. ...
... [3][4][5]15 In some patients, it has been reported that the supine sleep position is also associated with increased severity of sleep-disordered breathing (SDB), which includes snoring and obstructive sleep apnea. [17][18][19][20] Sleep-disordered breathing during gestation can increase the risk of a myriad of negative pregnancy outcomes, such as gestational diabetes, [22][23][24][25][26] gestational hypertension/preeclampsia, [21][22][23][24]26,27 preterm delivery 2,4,26,27 cesarean sections, 23,27 low birth weight, 24,27 small for gestational age (SGA), 27 and intensive care unit admissions. 22 In our study, 26 out of 300 women (8.7%) self-reported snoring, while 125 (41.7%) of them were not sure whether they snored or not. ...
... 82 When diagnosed, OSA in pregnancy can have an impact on maternal outcomes such as preterm birth. 83 OSA has also been associated with gestational diabetes and increased risk of hypertensive disorders of pregnancy. 82 OSA tends to be more prevalent in post-menopausal compared to pre-menopausal women. ...
... It is caused by repetitive upper airway collapse during sleep, resulting in intermittent hypoxia, sleep fragmentation, and sympathetic activation 1 . These physiological disturbances often lead to blood pressure and heart rate elevations, insulin resistance, and endothelial dysfunction, which are related to the occurrence of preeclampsia, pregnancy-induced hypertension, and gestational diabetes [2][3][4][5] . Without timely intervention, OSA will be associated with increasing risks for preterm birth, fetal growth restriction, cesarean delivery, perinatal depression, and reduced life quality [6][7][8][9] . ...
... OSA in pregnancy is linked to gestational hypertension, pre-eclampsia and eclampsia as well as unplanned caesarean section, pulmonary embolism, gestational diabetes and cardiomyopathy. [1][2][3][4][5] Maternal OSA is also associated with preterm birth and small for gestational age infants. 2 There are also likely longitudinal effects; moderate OSA in high-risk pregnancies is associated with increased risk of developmental delay seen in children aged 6-36 months. 6 The prevalence of OSA (defined as an Apnea Hypopnea Index ...
Objective
Obstructive sleep apnea (OSA) affects maternal and neonatal health during pregnancy. This study aimed to identify characteristics and comorbidities associated with sleep clinic referral in high‐risk pregnancies with Body Mass Index (BMI) ≥35 kg/m².
Method
Retrospective cohort study for individuals in a high‐risk pregnancy clinic at a tertiary Australian hospital from 1 January to 31 December 2020 with BMI≥35 kg/m². The primary outcome measure was sleep clinic referral. Exposure data included multiple comorbidities and formal tools (Epworth Sleepiness Scale and STOP‐BANG). Multivariable analysis was used to identify factors associated with referral. Descriptive data on barriers to diagnosis and treatment were collected.
Results
Of 161 pregnant individuals, 38.5% were screened using formal tools and 13.7% were referred to sleep clinic. Having STOP‐BANG performed was associated with sleep clinic referral (Odds Ratio: 18.04, 95% Confidence Interval:4.5–71.7, p < 0.001). No clinical characteristics were associated with the likelihood of performing STOP‐BANG. The COVID‐19 pandemic was a treatment barrier for three individuals.
Conclusions
Current screening practices identify pregnant individuals with the highest pre‐test probability of having OSA. Future research should evaluate real‐world strategies to improve identification and management in this high‐risk population.
... Considering the sleep scores, twins had a 0.26 higher score in perturbation and a 0.36 higher score in dysfunctionality than single pregnancies. Sleep disturbance has been linked with adverse obstetric outcomes such as placental abruption (Qiu et al., 2015), or abortions (Bourjeily et al., 2017). In a Taiwan cohort, it was demonstrated that women during the third trimester had more sleep disturbances and daytime dysfunction compared to Note: Data show median and interquartile range (Q1; Q3). ...
Women with twin pregnancies experience greater sleep disturbance compared to women with singleton pregnancies. The aims of this study were to explore the sleep quality in women with twin pregnancies and to compare their sleep dimensions with coetaneous single pregnancies. This was an observational study in which women were enrolled at the end of pregnancy in the Obstetric Service of Hospital La Paz (Spain). The women were classified as single ( n = 143) or twin pregnancy ( n = 62). Pregnant women responded to the Pittsburgh Sleep Quality Index to evaluate sleep quality, latency, duration, efficiency, perturbance, use of medication, and daytime dysfunction. The higher the index, the greater the alteration of sleep quality. Without statistical differences, a poor sleep quality was higher in women with single (66.7%) than women with twin pregnancies (22.8%). The good sleeper slept 6.8 h/day in single pregnancy and 7.3 h/day in twin pregnancy. The sleep perturbation and dysfunctionality were higher in women with twin than single pregnancies. The use of medication to sleep was significantly lower in women with twin than single pregnancies. In women with twin pregnancy, the body weight gain during first trimester had a positive correlation with worse sleep quality and sleep perturbations. Twin pregnancy needed more than 7 h/day to have a high sleep quality, showing greater sleep perturbations and daytime dysfunction than single pregnancies. The control of gestational body weight can improve the sleep quality, disturbances, and duration in twin gestations. Sleep screening during pregnancy would be necessary to handle sleep issues and increase benefits in twin gestational outcomes.
... OSA in pregnancy has been linked to gestational hypertension, diabetes, and cardiomyopathies which are all independent risk factors for AF as discussed previously (75. Furthermore, OSA in non-obese pregnant patients is associated with perinatal complications such as preeclampsia, and eclampsia [77]. ...
Postpartum atrial fibrillation is an uncommon but increasingly prevalent tachyarrhythmia that merits special management considerations with regards to the safety and efficacy of anticoagulation, rate and rhythm control as well as drug exposure to infants throughout breastfeeding. In this state-of-the-art review, we examine the demographics of postpartum atrial fibrillation with its associated risk factors, describe the safety of commonly used atrial fibrillation therapies, and discuss important considerations for women considering subsequent pregnancies.
... There is evidence supporting that OSA adversely affects almost every organ system and is associated with neurological, cardiovascular, respiratory, endocrine, gastrointestinal, obstetric, and perinatal health problems, perioperative complications, accidents, and mortality. [3][4][5][6][7][8][9] Untreated OSA puts patients at increased risk for death, particularly in patients less than 50 years of age. In addition, individuals with OSA bring significant costs to the health system and the general economy due to the increased risk of health complications, workplace errors, and traffic accidents. ...
... Pregnant women who slept 9 hours or more per day had an increased risk of GDM, while those who slept less than 7 hours had a slightly increased risk [59]. Data from other studies, including large-scale prospective cohort studies, also note that both short and long sleep duration, accompanied by sleep-disordered breathing, positively correlate with the incidence of GDM [60,61,62]. In a study involving 46 women with newly diagnosed GDM and 46 healthy pregnant women matched for age, gestational age, body mass index, and race, women with obstructive sleep apnea had a higher risk of GDM [63]. ...
Diabetes mellitus is the most common metabolic disorder during pregnancy. The International Diabetes Federation estimates that one in six pregnant women (16.8 %) has diabetes. The prevalence of this disease in the human population is striking and, according to various sources, accounts for 14–25 % of all pregnant women. Most cases of hyperglycemia during pregnancy (75–90 %) is due to gestational diabetes mellitus (GDM). Risk factors, etiology and pathophysiology of GDM are being actively studied, but there are still some controversial issues. For example, the development of GDM in the aspect of circadian rhythm disorders. This problem is especially relevant in connection with pregnancy. After all, there is a two-way relationship here – circadian rhythm disorders affect the course of pregnancy, and pregnancy can be the cause of these disorders. In addition, this problem is relevant for women with a history of endocrine disorders, including diabetes mellitus, as there is a clear link between circadian rhythms and the production of hormones, including insulin. The aim of this review was to show the relationship between the development of GDM, its complications, and circadian rhythm disorders in women. Pregnancy complicated by GDM can have a negative effect on the myocardium and liver. Moreover, this disease has a significant impact on the myocardium of the offspring. GDM also can cause other complications for the mother’s health and fetus or newborn. Scientists have identified a fairly significant number of risk factors for GDM. However, circadian rhythm disorders accompanying pregnancy are often underestimated as a risk factor. In general, there are many controversies regarding the relationship between long / short sleep duration and quality and the risk of developing diabetes, as well as how melatonin and its precursor serotonin affect metabolism in critical organs. Thus, the role of circadian rhythm disorders in the development of diabetes and its consequences is not yet fully understood. It is likely that solving the problem of circadian rhythm disorders will be the key to overcoming a significant proportion of cases of GDM. Therefore, there is an urgent need for further, larger-scale studies to investigate the causal links between circadian rhythm disorders, diabetes mellitus, and pregnancy.
... Gestational OSA has been extensively associated with cardiovascular disorders during pregnancy. Numerous studies have consistently shown an increased risk of gestational hypertension, preeclampsia, and cardiomyopathy in pregnant women with OSA [31][32][33]. However, the causal relationship between OSA and gestational hypertension has not been sufficiently validated. ...
Obstructive sleep apnea (OSA) is a recognized risk factor for gestational hypertension, yet the exact mechanism behind this association remains unclear. Here, we tested the hypothesis that intermittent hypoxia (IH), a hallmark of OSA, induces gestational hypertension through perturbed endothelin-1 signaling. Pregnant Sprague–Dawley rats were subjected to normoxia (control), mild IH (mIH, 10.5% O2), or severe IH (sIH, 6.5% O2) from gestational day 10–21. Blood pressure (BP) was monitored. Plasma was collected and mesenteric arteries were isolated for myograph and protein analyses. The mIH and sIH groups demonstrated elevated BP, reduced plasma nitrate/nitrite (NOx), and unchanged endothelin-1 levels compared to the control group. Western blot analysis revealed decreased expression of endothelin type B receptor (ETBR) and phosphorylated endothelial nitric oxide synthase (eNOS), while the levels of endothelin type A receptor (ETAR) and total eNOS remained unchanged following IH exposure. The contractile responses to potassium chloride, phenylephrine, and endothelin-1 were unaffected in endothelium-denuded arteries from mIH and sIH rats. However, mIH and sIH rats exhibited impaired endothelium-dependent vasorelaxation responses to ETBR agonist IRL-1620 and acetylcholine compared to controls. Endothelium denudation abolished IRL-1620-induced vasorelaxation, supporting the involvement of endothelium in ETBR-mediated relaxation. Treatment with IRL-1620 during IH exposure significantly attenuated IH-induced hypertension in pregnant rats. This was associated with elevated circulating NOx levels, enhanced ETBR expression, increased eNOS activation, and improved vasodilation responses. Our data suggested that IH exposure during gestation increases BP in pregnant rats by suppressing ETBR-mediated signaling, providing a molecular mechanism linking IH and gestational hypertension.
... Bu sonuç literatürü desteklemektedir (63). Gebelikte uyku apnesinin olumsuz obstetrik sonuçları bulunmaktadır (64,65). Giderek artan obezite prevelansı ve bu riskler göz önünde bulundurulduğunda, obezite ve buna bağlı gelişen uyku apnesinin yönetimi için stratejiler geliştirilmesine ihtiyaç olduğu ve ebelerin obez gebelerde uyku apnesi riskini dikkate almaları gerektiği söylenebilir. ...
Amaç: Bu çalışma, birincil çalışmalara dayalı olarak, maternal obezitenin anne-bebek sağlığına etkilerinin belirlemesi amacı ile yapılmıştır. Yöntem: Sistematik derleme ve meta-analiz niteliğinde olan bu çalışmada, PRISMA kontrol listeleri kullanılmıştır. Çalışma için taramalar Eylül-Ekim 2021 tarihlerinde yapılmış ve Aralık 2022’de güncellenmiştir. Taramalar, PubMed, MEDLINE, theCochrane Library, EBSCO, Web of Science, Ulusal Tez MerkeziveDergiPark arama motorlarından yapılmıştır. Taramalarda obesity* AND (pregnancy*OR “babieshealth” OR “maternalHealth” OR management) kelime ve kelime grupları kullanılmıştır. Araştırmaların metodolojik kalitesi, JoannaBriggsInstitute tarafından geliştirilen “Kritik Değerlendirme Kontrol Listeleri” ile değerlendirilmiştir. Veriler meta-analiz yöntemleri ile sentez edilmiştir. Bulgular: Çalışmaya 2013-2022 yıllarında yayımlanmış 38araştırma dahil edilmiştir. Araştırmaların toplam örneklem hacmi 784265’tir. Yapılan meta-analizlerde maternal obezitenin istatistiksel olarak anlamlı bir şekilde, gestasyonel diyabet oluşumunu 4.09 kat (z=12.07, p<0.00001), gebelikte hipertansiyonu 4.83 kat (z=11.25, p<0.00001) ve preeklampsiyi ise3.34 kat (z=37.91, p<0,00001) arttırdığı saptanmıştır. Ayrıca maternal obezitenin sezaryen doğum, doğumda indüksiyon kullanımı, bebeğin doğum ağırlığı, preterm doğum, gebelik ayına göre iri bebek, makrozomi ve postpartum kanama gelişme olasılığını istatistiksel olarak anlamlı bir şekilde arttırdığı, spontan vajinal doğum vegebelik ayına göre küçük bebek olasılığını azalttığı saptanmıştır. Sonuç: Bu çalışmada, maternal obezitenin anne-bebek sağlığı ile ilgili birçok parametrede olumsuz sonuçları olduğu sonucuna ulaşılmıştır. Kadınların gebeliğe normal kilo ile başlamalarının ve gebelik sürecinde maternal obezitenin yönetiminin sağlanması, anne-bebek sağlığının gelişimine katkıda bulunulabilir
... The results from a large cohort study suggest that OSAS is associated with an increased risk of preeclampsia, eclampsia, and gestational diabetes, even after controlling for obesity. 562 Another retrospective population-based dataset study found an increased risk of preeclampsia among pregnant women with OSAS, and these differences remained significant after controlling for obesity. 563 Moreover, experimental studies in animals have found that pregnant rodents subjected to chronic hypoxia developed preeclampsia-like symptoms. ...
Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.
... associated with an increased risk for gestational diabetes [8,9], hypertensive disorders of pregnancy [8,10,11], preterm birth [8,11], severe maternal morbidity, and depressive symptoms [12]. Babies born to mothers with a diagnosis of obstructive sleep apnea are also more likely to be admitted to the intensive care unit, to require airway intubation and resuscitation, and to be diagnosed with a congenital anomaly [12,13]. ...
Little is known about the association between sleep and diet in pregnancy, despite both behaviors impacting maternal and fetal health. We aimed to perform a systematic review of the available literature on associations between sleep characteristics and dietary intake and eating behaviors during pregnancy, reporting on both maternal and fetal outcomes. We followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and conducted our search on 27 May 2021 in the PubMed, EMBASE, and CINAHL databases. The search yielded 6785 unique articles, of which 25 met our eligibility criteria. The studies, mostly observational, published 1993–2021, include data from 168,665 participants. Studies included examinations of associations between various maternal sleep measures with a diverse set of diet-related measures, including energy or nutrient intake (N = 12), dietary patterns (N = 9), and eating behaviors (N = 11). Associations of maternal exposures with fetal/infant outcomes were also examined (N = 5). We observed considerable heterogeneity across studies precluding our ability to perform a meta-analysis or form strong conclusions; however, several studies did report significant findings. Results from this systematic review demonstrate the need for consistency in methods across studies to better understand relationships between diet and sleep characteristics during pregnancy.
... Although the severity and symptoms of OSA can improve once the acute phase of stroke has passed (3-6 months), they do not resolve completely, suggesting that OSA may have been present in patients before the index stroke. In pregnancy, OSA is associated with a higher risk of pre-eclampsia, eclampsia, and gestational diabetes mellitus [44]. ...
Obstructive sleep apnea (OSA) is highly prevalent in the general population. In addition, patients with comorbid OSA are frequently hospitalized for unrelated conditions. This review focuses on managing patients with comorbid OSA in inpatient and acute care settings for inpatient providers. OSA can impact the length of stay, the risk of intubation, the transfer to the intensive care unit, and mortality. Screening questionnaires such as STOP-BANG can help with screening hospitalized patients at admission. High-risk patients can also undergo additional screening with overnight pulse oximetry, which can be used to guide management. Options for empiric treatment include supplemental oxygen, continuous positive airway pressure therapy (CPAP), auto adjusting-PAP, bilevel positive airway pressure therapy (BPAP), or high-flow nasal cannula. In addition, discharge referral to a board-certified sleep physician may help improve these patients’ long-term outcomes and decrease readmission risks.
... Furthermore, there is scarce evidence for SDB during pregnancy influencing adverse perinatal outcomes such as intrauterine growth restriction (IUGR), preterm birth, low birthweight (LBW), and low Apgar scores [10,11]. Moreover, cohort studies investigating the association of sleep disorders and adverse pregnancy outcomes, enabling determination of temporal associations between these factors, are limited [4,8,12,13], and no population-based study has fully characterised the longitudinal links between potential risk factors for SDB, incidence of SDB during each pregnancy trimester and the postpartum period, and adverse pregnancy outcomes. Furthermore, how sleep disorders during pregnancy influence women's health in the short or longer term has not been determined. ...
Sleep disorders could influence pregnancy outcomes but evidence for longitudinal associations is scarce. We established a prospective cohort of women to determine incident sleep issues and their adverse health outcomes during pregnancy and beyond, and present here the baseline cohort profile. Antenatal women in gestational weeks 8–12 were recruited (n = 535) and followed-up in each trimester and at 5–6 weeks postpartum (no attrition). Sleep symptoms and disorders were measured using STOP-Bang and Berlin questionnaires and Pittsburgh Sleep Quality Index. Incident health outcomes were extracted from clinical records. At the time of recruitment, habitual snoring was present in 13.8% of participants; “excessive sleepiness during the day” (EDS) in 42.8%; short (<7 h) sleep duration in 46.4%; “having trouble sleeping” in 15.3%; and “poor subjective sleep quality” in 8.6%. Habitual snoring was strongly associated with irregular menstrual periods for one year preceding pregnancy (p = 0.014) and higher BMI (p < 0.001). Higher age was associated with less “trouble sleeping” (OR 0.9, p = 0.033) and longer sleep duration was associated with better “subjective sleep quality” (OR 0.8, p = 0.005). Sleep issues were highly prevalent at baseline and associated with age, irregular menstruation, and obesity. This cohort will provide a robust platform to investigate incident sleep disorders during pregnancy and their effects on adverse pregnancy outcomes and long-term health of women and their offspring.
... The major citing articles in cluster #6 were authored by Dominguez et al. [178], with a coverage of 17 articles and a GCS of 17; Dominguez et al. [179], with a coverage of 17 articles and a GCS of 25; and Subramani et al. [180], with a coverage of 15 articles and GCS of 76. The main theme of cluster #6 is OSA during pregnancy, which can be observed from the citing articles [178,179,[181][182][183][184][185] and the cited references [186][187][188][189][190][191][192]. Notably, the prevalence of OSA ranges from 15 to 20% in obese pregnant women [179]. ...
Obstructive sleep apnea (OSA) is a common sleep disorder that has a high prevalence in the obese population. Studies have established the relationship between OSA and a multitude of adverse health outcomes including cardiovascular diseases and metabolic diseases, indicating the nature of OSA as a disorder with high comorbidity and mortality. Thus, OSA is a growing public health concern in the face of rising obesity trends globally. This study conducted a systematic analysis of the scientific literature on OSA from 1977 to 2022 in order to gain a better understanding of major research areas concerning OSA and the connections between these areas. Findings indicate that there are major clusters investigating the relationship between OSA and cardiovascular and metabolic diseases, which are health conditions commonly associated with obesity and have a significant disease burden. The findings from this scientometric analysis also indicate emerging clusters of research into more specific populations such as children with obesity and pregnant women.
... Pregnancy is a vulnerable period for development or worsening of obstructive sleep apnoea (OSA) 1 that could be continuation or worsening of pre-existing OSA or new onset OSA caused by physiological changes specific to the pregnancy (gestational OSA). 1 This gestational OSA results from oedema of the upper airway and higher negative upper airway pressure that results from respiratory-driven changes caused by elevated oestrogen and progesterone levels. 1 The prevalence of gestational OSA which is around 10.5% in early pregnancy increases during second and third trimesters of the pregnancy becoming as high as 26% in the third trimester. [1][2][3] Limited evidence suggests that OSA during pregnancy is associated with maternal, foetal and neonatal morbidities. 4 OSA was reported to be associated with maternal complications like cardiomyopathy, congestive heart failure, pulmonary embolism and metabolic disorders including gestational diabetes mellitus (GDM), pregnancy induced hypertension(PIH), 4 maternal obesity, and preeclampsia, 5 and to increase the incidence of elective and emergency caesarean deliveries and assisted vaginal deliveries. ...
Introduction: Screening can facilitate early detection and management of obstructive sleep apnoea (OSA) during pregnancy and improve pregnancy outcomes. Our aim was to determine the validity of the Sinhala translation of the Berlin and STOP-Bang questionnaires to detect the OSA risk among Sri Lankan antenatal women. Methods: Berlin and the STOP-Bang questionnaires were translated to Sinhala language using the standard translation/ back-translation method. Face, content, and consensual validity of the Sinhala versions of Berlin (Berlin-S) and STOP-Bang (STOPBang-S) questionnaires were determined through a modified Delphi process conducted among respiratory physicians. These validated versions were administered to 200 antenatal women at selected antenatal clinics. The exploratory and confirmatory factor analyses (EFA and CFA) were performed. Internal consistency was assessed. Test-retest reliability and Inter-interviewer reliability for these questionnaires were assessed using Cohen’s kappa (k) and intra class correlation coefficient (ICC) values, respectively. Results: Berlin-S and STOP-Bang-S showed good content, consensual and face validity. The EFA for Berlin-S confirmed a three-factor model compatible with the original instrument but CFA confirmed a one-factor model. The EFA for STOP-Bang-S confirmed a two-factor model. The CFA confirmed a one-factor model that was compatible with the original factor structure. The internal consistency of Berlin-S and STOP-Bang-S were satisfactory. Testretest reliability of Berlin-S and STOP-Bang-S were high for Berlin-S categories (k 0.828 [95% CI: 0.65-1.00]) and STOP-Bang-S score (ICC 0.982 [95% CI: 0.954-0.993]) respectively. The Cohen’s kappa value for the Inter-interviewer reliability of Berlin-S categories was 1.00 (95% CI: 1.00-1.00) and the ICC of STOP-Bang-S total score were 0.992 (95% CI: 0.960-0.994). Conclusions: The Sinhala versions of Berlin and STOP-Bang questionnaires are valid and reliable tools to screen for OSA risk among antenatal women in Sri Lanka.
... depending on the study [20]. Previous research has suggested a relationship between hypertension diseases and OSA [13,[21][22][23]. The incidence of OSA varies widely among studies of women with hypertension. ...
Objectives: The primary objective of this study was to determine the incidence of obstructive sleep apnoea (OSA) in pregnant women with chronic hypertension. The secondary objectives were to define the risk factors and assess the maternal-foetal consequences in this population.
Methods: This was a single-centre, retrospective study. The participants were pregnant women with chronic hypertension in the Department of Internal Medicine of Beijing Obstetrics and Gynaecology Hospital, Capital Medical University, between January 2019 and November 2020. Overnight polysomnography (PSG) was performed to diagnose OSA. A total of 99 pregnant women with chronic hypertension who underwent PSG for the first time were included. We reviewed the medical records and collected baseline data, obstetrics, and neonatal information. IBM SPSS Statistics version 25.0 was used for data analysis.
Results: Of the 99 women with chronic hypertension, 63 (63.6%) were diagnosed with OSA, including 41 with mild OSA, 14 with moderate OSA, and eight with severe OSA. Comparing the two groups of chronic hypertensive pregnant women with OSA and those without OSA, the OSA group had higher mean pre-pregnancy body mass index (BMI, 30.68±5.19 vs 27.11±5.22, P=0.001), higher rate of gestational diabetes mellitus (GDM, 38.1% vs 13.9%, P=0.011), a higher induction rate (33.3% vs 11.1%, P=0.014), higher vaginal delivery rate (33.9% vs 13.3%, P=0.034), and a lower caesarean section rate (86.1% vs 66.7%, P=0.034). No significant differences were found in the other evaluated indicators.
Conclusion: The incidence of OSA in pregnant women with chronic hypertension was high in this study. A higher pre-pregnancy BMI is a risk factor for OSA in this population. Pregnant women with chronic hypertension and OSA had a higher risk of developing GDM but a lower rate of caesarean section.
... Maternal-fetal outcomes have been studied extensively in obstructive sleep apnea 14,15 , but studies on narcolepsy are lacking. Prior studies have included retrospective case-control and cohort designs. ...
Objective: We sought to determine whether narcolepsy in pregnancy is associated with adverse maternal-fetal outcomes.
Material and Methods: A retrospective, cross-sectional analysis was performed using the nationwide inpatient sample (NIS) for the period 2008-2017. The primary exposure was narcolepsy with cataplexy, narcolepsy type 1 (NT1), and without cataplexy, narcolepsy type 2 (NT2), and the endpoints were a composite of maternal-fetal outcomes or risk factors.
Results: A total of 7,742 hospitalizations among pregnant women with narcolepsy were identified (prevalence = 17.6 per 100,000), of which 6,769 (88%) were diagnosed with NT2. Statistically significant positive associations were found between narcolepsy and the following conditions: obesity (odds ratio (OR): 2.99, confidence interval (CI): 2.4-3.74), anemia (OR=1.41, CI: 1.13-1.77), pre-pregnancy hypertension (OR=1.93, CI: 1.37-2.7), pre-pregnancy diabetes (OR=1.7, CI: 1.08-2.84), and gestational hypertension (OR=1.58, CI: 1.13-2.20) in the ICD-9 group. Similar findings were noted in the ICD-10 group with the exception of gestational hypertension, gestational diabetes, and anemia.
Conclusion: Given these important findings, we propose a global approach of screening for narcolepsy among women of reproductive age with pre-existing risk factors prior to conception to minimize pregnancy complications.
... In all the four cohort studies which looked at the impact of OSA on pregnancy-related outcomes, an outcome of which was undefined post-operative wound complications, adjusted odds ratios were found to show an association between OSA and wound healing. Whilst Louis et al. [19] and Bourjeily [20] reported adjusted odds ratios with almost double the risk of wound complications in patients diagnosed with OSA; Louis [21] and Spence [22] reported odds ratios with wide confidence intervals spanning the value of 1. ...
Purpose
Obstructive sleep apnoea (OSA) is a common, significantly underdiagnosed sleep-related breathing disorder, characterised by upper airway collapse and resultant intermittent hypoxia. Oxygen plays an important role in collagen synthesis and as a result in wound healing. An association between OSA and wound healing has not been clearly delineated. A systematic review was performed to understand this association.
Methods
Randomised controlled trials, cohort, cross-sectional and case–control studies evaluating the relationship between OSA or OSA-related symptoms and wound healing in adult populations were searched in the systematic review using electronic databases PubMed, EMBASE and Ovid MEDLINE.
Main results
A total of 11 cohort studies and 1 case–control study with a total of 58,198,463 subjects were included. Most studies suggest that patients diagnosed with OSA or who are at high risk of having OSA are more likely to suffer from wound complications. Patients with OSA have been found to be at higher risk for post-operative wound infection and wound dehiscence. Contradictory results were obtained on time to heal, with one study concluding that individuals with OSA were more likely to heal earlier when compared to patients without OSA. Quality of evidence, however, was deemed very low due to high risk of bias.
Conclusions
This systematic review did identify an association between OSA and wound healing. However, due to the very low-quality evidence, further research is warranted to better characterise this association and investigate whether or not treating OSA can indeed affect wound healing.
... OSA is known to affect the functional outcomes of many organ systems in pregnant women; however, the cardiovascular system is particularly susceptible to intermittent hypoxic episodes. Indeed, previous cohort studies have reported that gestational OSA is associated with increased risks of maternal hypertension [5][6][7], cardiomyopathy, and congestive heart failure [8]. The mechanisms underlying the increased risk for maternal cardiovascular pathology in OSA patients are unclear, but animal models of intermittent hypoxia mimicking hypoxia-reoxygenation events implicate inflammation and oxidative stress as important mediators [9][10][11][12]. ...
Obstructive sleep apnea (OSA) is a chronic condition frequently observed in pregnant women. We have shown that gestational intermittent hypoxia (GIH), a hallmark of OSA, leads to sex-specific impairment in the endothelium-dependent relaxation response and an increase in blood pressure in adult male but not female rat offspring. The present study tested the hypothesis that functional ovaries normalize GIH-induced hypertensive response in female offspring. Experiments were done in female offspring of pregnant rats exposed to normoxia or GIH (FIO2 21-10.5% from gestational days 10 to 21). Ovariectomy and sham surgery were performed at 5 weeks of age. Pups born to GIH dams were significantly smaller than the controls, but they exhibited catch-up growth and were similar to controls by 5 weeks of age. Ovariectomy significantly exacerbated bodyweight gain to a similar extent in both control and GIH offspring. Marked increases in blood pressure were observed in pre-pubertal GIH offspring compared to controls; however, after puberty, blood pressure in GIH offspring progressively decreased and became normotensive at adulthood. Ovariectomy led to the maintenance of higher blood pressure in post-pubertal GIH offspring with no significant effect in controls. Vascular contractile and relaxation responses were not affected in the GIH and control offspring; however, ovariectomy selectively decreased endothelium-dependent relaxation response along with a decrease in endothelial nitric oxide synthase expression in the GIH offspring. These findings suggest that functional ovaries are crucial in protecting females against GIH-mediated endothelial dysfunction and hypertension in adulthood.
Importance
Pregnancy may contribute to the development or exacerbation of obstructive sleep apnea (OSA) and increase the risk of gestational complications. Continuous positive airway pressure (CPAP) is the first-line and criterion standard treatment for OSA and is regarded as the most feasible choice during pregnancy. However, the association between CPAP therapy in pregnant women with OSA and reduced gestational complications remains inconclusive.
Objective
To investigate the association between CPAP therapy in pregnant women with OSA and the reduction of adverse hypertensive outcomes during gestation.
Data Sources
Keyword searches of PubMed, Embase, and the Cochrane Database of Systematic Reviews and Clinical Trials were conducted from inception to November 5, 2023.
Study Selection
Original studies reporting the treatment effect of CPAP use on lowering hypertension and preeclampsia risks in pregnant women with OSA were selected.
Data Extraction and Synthesis
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed in the reporting of reviews. Data were independently extracted by 2 authors. Random-effects model meta-analyses were performed and risk ratios (RRs) reported. Subgroup analysis, meta-regression based on age and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), and publication bias assessment were also conducted.
Main Outcome and Measures
The primary outcome was the RR of gestational hypertension and preeclampsia between pregnant women with OSA receiving CPAP treatment and those who did not receive CPAP treatment.
Results
Six original studies in 809 participants (mean age, 31.4 years; mean BMI, 34.0) were identified and systematically reviewed for meta-analysis. The pooled results showed significant differences between the intervention (CPAP use) and the control (non-CPAP use) groups in reducing the risk of gestational hypertension (RR, 0.65; 95% CI, 0.47-0.89; P = .008) and preeclampsia (RR, 0.70; 95% CI, 0.50-0.98; P = .04). Meta-regression revealed that patients’ age (coefficient, −0.0190; P = .83) and BMI (coefficient, −0.0042; P = .87) were not correlated with reduction of risk of hypertension and preeclampsia.
Conclusions and Relevance
These findings suggest that implementing CPAP treatment in pregnant women with OSA may reduce the risk of gestational hypertension and preeclampsia.
Obstructive sleep apnea (OSA) is quite prevalent during pregnancy and is associated with adverse perinatal outcomes, but its potential influence on fetal development remains unclear. This study investigated maternal OSA impact on the fetus by analyzing gene expression profiles in whole cord blood (WCB). Ten women in the third trimester of pregnancy were included, five OSA and five non-OSA cases. WCB RNA expression was analyzed by microarray technology to identify differentially expressed genes (DEGs) under OSA conditions. After data normalization, 3238 genes showed significant differential expression under OSA conditions, with 2690 upregulated genes and 548 downregulated genes. Functional enrichment was conducted using gene set enrichment analysis (GSEA) applied to Gene Ontology annotations. Key biological processes involved in OSA were identified, including response to oxidative stress and hypoxia, apoptosis, insulin response and secretion, and placental development. Moreover, DEGs were confirmed through qPCR analyses in additional WCB samples (7 with OSA and 13 without OSA). This highlighted differential expression of several genes in OSA (EGR1, PFN1 and PRKAR1A), with distinct gene expression profiles observed during rapid eye movement (REM)-OSA in pregnancy (PFN1, UBA52, EGR1, STX4, MYC, JUNB, and MAPKAP). These findings suggest that OSA, particularly during REM sleep, may negatively impact various biological processes during fetal development.
Obstructive sleep apnea (OSA) is a prevalent yet underdiagnosed condition in pregnancy, associated with various maternal and fetal complications. This review synthesizes the current evidence on the epidemiology, pathophysiology, and neurological consequences of OSA in pregnancy, along with the potential management strategies. Articles were sourced from the PubMed, EMBASE, and Cochrane databases until 2023. Our comprehensive review highlights that the incidence of OSA increases during pregnancy due to physiological changes such as weight gain and hormonal fluctuations. OSA in pregnancy is linked with gestational hypertension, pre-eclampsia, gestational diabetes, and potential adverse fetal outcomes such as intrauterine growth restriction and preterm birth. Continuous positive airway pressure (CPAP) therapy remains the most effective management strategy for pregnant women with OSA. However, adherence to CPAP therapy is often suboptimal. This comprehensive review underscores the importance of the early recognition, timely diagnosis, and effective management of OSA in pregnancy to improve both maternal and fetal outcomes. Future research should focus on enhancing screening strategies and improving adherence to CPAP therapy in this population.
Study Objectives
Subjective recall of supine sleep during pregnancy has been linked to increased risk of stillbirth, but longitudinal, objective data are lacking. We aimed to examine how sleep position and breathing parameters change throughout pregnancy, and investigated associations between maternal supine sleep, assessed objectively in early and late gestation, and fetal growth velocity in high-risk women.
Methods
Women with singleton pregnancies and body mass index (BMI) ≥27 kg/m2 underwent level-III sleep apnea testing. Sleep position was assessed by accelerometry. We derived percentiles of estimated fetal weight and birthweight using FetalGPSR software, then calculated growth velocity as change in percentile/week between the second trimester anatomy scan and birth.
Results
In total, 446 women were included, with N=126 in the longitudinal sleep pattern analysis and N=83 in the fetal growth analysis. Sleep onset position and predominant sleep position were significantly correlated in both early (p=0.001) and late (p<0.01) pregnancy. However, supine going-to-bed position predicted predominant supine sleep in only 47% of women. Between early and late pregnancy there was a reduction in predominant supine sleepers (51.6% to 30.2%). Percent of sleep spent supine and oxygen desaturation index, in the third trimester, were significantly associated after BMI adjustment (B=0.018, p=0.04). Models did not suggest significant effects of early or late pregnancy supine sleep on growth velocity (p>0.05).
Conclusion
Going-to-bed position predicts predominant supine sleep in less than half of women with overweight and obesity. Time spent supine throughout pregnancy correlates with measures of sleep-disordered breathing. Maternal sleep position patterns did not affect fetal growth velocity in this high-risk population.
This chapter discusses the impact of changes in sleep architecture and sleep disorders in pregnancy both on maternal health and health of the baby. Changes in sleep architecture occur as a result of physiological and hormonal reasons as well as a result of the physical discomfort from an enlarging uterus. These changes in sleep architecture have been determined using both subjective and objective measures such as sleep diaries, actigraphy, and polysomnography. Physiological changes during pregnancy and comorbid conditions can lead to sleep fragmentation, changes in timing and duration of sleep, as well as sleep disorders such as sleep disordered breathing (SDB), restless leg syndrome (RLS), and insomnia. Each of these disorders in turn has an adverse impact on maternal and fetal health. Gestational diabetes, hypertensive disorders of pregnancy as well as peripartum depression and postpartum weight retention are well known consequences of SDB, RLS, and insomnia. The pathophysiological mechanisms by which SDB leads to gestational diabetes and hypertension include common pathways of oxidative stress, sympathetic activation, and activation of inflammatory mediators. Fetal consequences include intrauterine growth retardation, preterm births, and low gestational weight. Pregnancy complicates the management of pre-existing sleep disorders such as narcolepsy due to concerns for teratogenicity of drugs used for the treatment. Similarly, treatment of sleep disorders such as RLS and insomnia complicating pregnancy requires special consideration as well. Management of these conditions includes nonpharmacological and carefully considered pharmacological measures so as to ameliorate the effect of these sleep disorders on both the mother and the baby.
Cardiovascular disease is the leading cause of pregnancy-related death in the United States. The increasing rates of several cardiovascular risk factors including obesity, sleep apnea, diabetes, hypertension, hyperlipidemia, smoking, and sedentary lifestyle may play a role in the rise in maternal mortality observed in the United States. Maternal risk factors for cardiovascular disease are also associated with increased maternal and fetal morbidity and mortality. For women pursuing pregnancy, addressing these risk factors by screening and treating early may mitigate both peripartum maternal and fetal risks.KeywordsCardiovascular diseaseObesityHypertensionSleep apneaDiabetesTobaccoExerciseHyperlipidemia
Study objectives:
Could HSAT using a type III portable monitor (PM) Nox-T3 detect OSA in pregnant women?
Methods:
92 pregnant women (34.5 ± 4.3 years old, gestational age 25.4 ± 8.9 weeks, BMI 29.9± 4.7 kg/m2) with suspected OSA underwent HSAT with the Nox-T3 PM followed by an overnight polysomnogram (PSG) and PM recording simultaneously in the laboratory within one week. PMs were scored automatically and manually using a 3% criteria, and compared to PSGs scored by following guidelines.
Results:
Apnea-hypopnea index (AHI) was 8.56 ± 10.42, 8.19 ± 13.79, 8.71 ± 14.19 on HSAT, in-laboratory PM recording and PSG (p= 0.955), respectively. Bland-Altman analysis of AHI on PSG versus HSAT showed a mean difference (95% confidence interval) of -0.15 (-1.83, 1.53); limits of agreement (= ± 2 standard deviations) was -16.26 to 16.56 events/h. Based on a threshold of AHI ≥ 5 events/h, HSAT had 91% sensitivity, 85% specificity, 84% positive predictive value, 92% negative predictive value compared to PSG. When comparing the simultaneous recordings, closer agreements were observed. Automated vs. manual analysis of PM were no different.
Conclusions:
A type III PM had an acceptable failure rate and high diagnostic performance operating as a reasonable alternative for in-laboratory PSG in pregnant women.
Purpose
The aim of this study is to detect the prevalence of obstructive sleep apnea syndrome (OSAS) in patients having lone atrial fibrillation (AF).
Patients and methods
Fifty patients with lone AF were referred to our sleep unit from the Department of Cardiology at the University Hospital. Lone AF was defined as AF in patients without cardiac structural abnormality and less than 60 years of age.
All patients were subjected to a detailed history with stress on the number and date of documented episodes of AF and how it was terminated, OSA symptoms (excessive daytime sleepiness, witnessed apnea, loud habitual snoring, and nocturnal choking), and OSA screening questionnaires. ENT and cardiac examination by a specialist was done.
Full-night attended polysomnography was performed on full night.
Results
The median apnea–hypopnea index in the studied group was 10.8 (range, 0.4–69.4). There were 21 (42.0%) non-OSA patients, while there were 29 (58%) OSA patients. There were eight (27.6%) mild OSA patients. Moderate OSA patients were 10 (34.5%). Severe OSA patients were 11 (37.9%). Median of the frequency of AF episodes in the last 1 year was significantly higher in the OSA group than in the normal group ( P =0.01). No significant difference was present between both groups as regards the number of nocturnal arrhythmias not related to respiratory events. The frequency of paroxysmal AF episodes during the last year shows a significant positive correlation with severity of OSA, desaturation index, and total arousal index.
Conclusion
The results of our study support our hypothesis that OSA is a risk factor for AF. We should investigate patients with lone AF for the possibility of OSA.
The Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology tasked an expert group to review existing evidence and to generate recommendations on the screening, diagnosis, and treatment of patients with obstructive sleep apnea during pregnancy. These recommendations are based on a systematic review of the available scientific evidence and expert opinion when scientific evidence is lacking. This guideline may not be appropriate for all clinical situations and patients, and physicians must decide whether these recommendations are appropriate for their patients on an individual basis. We recognize that not all pregnant people may identify as women. However, data on non-cisgendered pregnant patients are lacking, and many published studies use gender-binary terms; therefore, depending on the study referenced, we may refer to pregnant individuals as women. This guideline may inform the creation of clinical protocols by individual institutions that consider the unique considerations of their patient populations and the available resources.
Objetivo: desenvolver, com base na investigação de artigos científicos publicados, a relação da Apneia Obstrutiva do Sono durante a gravidez e seus impactos negativos na saúde materno-fetal. Metodologia: revisão bibliográfica de trabalhos publicados que abordaram o tema entre os anos de 2002 a 2023. Resultados: da pesquisa inicial provieram 452 estudos, após inspeção de títulos e resumos, 33 deles foram elegidos para análise. No balanço de elegibilidade, 21 foram classificados como elegíveis e 7 inelegíveis para inclusão. Conclusão: após exploração e verificação minuciosa dos artigos, evidencia-se a relação íntima entre a apneia obstrutiva do sono e os desfechos nocivos à saúde materna e fetal, principalmente aqueles relacionados à enfermidades que cursam especificamente com o período da gravidez, como pré-eclâmpsia, hipertensão gestacional e diabetes gestacional. No entanto, a escassez de estudos direcionados a estes dois grupos de pacientes, impossibilita a garantia de que estes estejam sendo efetivamente bem diagnosticados e tratados. Assim sendo, o desenvolvimento de mais estudos acerca do tema é urgentemente necessário.
Sleep-disordered breathing (SDB) is a common condition that is especially prevalent in patients with underlying cardiometabolic comorbidities. Increasing evidence supports not only an association but also a causal relationship between types of SDB and the incidence and morbidity of hypertension, coronary heart disease, arrhythmia, heart failure, stroke, diabetes, and possibly high-risk pregnancy conditions. The recognition and treatment of SDB may have important implications for cardiac and metabolic outcomes. This chapter will review the pathophysiology and mechanisms of SDB and discuss the links between SDB and its treatments on cardiovascular diseases and their outcomes.KeywordsSleep-disordered breathing (SDB)Obstructive sleep apnea (OSA)Central sleep apnea (CSA)Apnea Hypopnea Index (AHI)Continuous positive airway pressure (CPAP)High loop gainCardiovascular diseaseAtrial fibrillation (AF)Congestive heart failure (CHF)Hypertension (HTN)
Uyku, kişilerin genel sağlığını ve yaşam kalitesini etkileyen önemli bir biyolojik süreçtir. Uyku vücudun toparlanması, hücrelerin onarımı, doku büyümesi, hormonların salınımı gibi birçok süreçlerde görev almaktadır. Özellikle gebelik sürecinde meydana gelen değişikliklere uyum sağlanmasında, fetal gelişimde, doğum ve doğum sonu dönemlerde gerekli olan enerjini sağlanabilmesinde ve komplikasyonların minimum seviyeye indirgenmesi açısından son derece mühimdir. Gebelik sürecinde yaşanan fiziksel (gastrointestinal rahatsızlıklar, sırt ağrısı vb.) ve hormonal değişimler (östrojen, oksitosin vb.) uyku ve uyku kalitesinde önemli farklılıklara sebep olabilmektedir. Bunun yanı sıra gebelik sürecinde huzursuz bacak sendromu ve solunum bozukluğu rahatsızlıkları uyku sorununu daha şiddetli hale getirebilmektedir. Gebelik sürecinde yaşanan uyku sorunları maternal ve fetal komplikasyon riskini artırmaktadır. Bu nedenle gebelik sürecinde uyku anne ve bebek sağlığı açısından daha fazla önemli hale gelmektedir. Erken dönemde uyku bozukluklarının tanımlanması, uykusuzluğun sağlık üzerindeki etkileri konusunda farkındalığın artırılması ve risk altında bulunan gebelere uygun girişimler sağlanarak meydana gelebilecek olası komplikasyonların en aza indirgenmesi gebelik sürecinin sağlıklı geçirilmesi açısından son derece önemlidir. Bu derleme makalede gebelik döneminde trimesterlere göre yaşanan uyku sorunları, gebelikte uyku bozukluklarına neden olan sorunlar, önemleri ve komplikasyonların ortaya konulması amaçlanmıştır.
Background:
Population-level data on obstructive sleep apnea among pregnant women in the United States and associated risk for adverse outcomes during delivery may be of clinical importance and public health significance.
Objective:
This study aimed to assess trends in and outcomes associated with obstructive sleep apnea during delivery hospitalizations.
Study design:
This repeated cross-sectional study analyzed delivery hospitalizations using the National Inpatient Sample. Temporal trends in obstructive sleep apnea were analyzed using joinpoint regression to estimate the average annual percentage change with 95% confidence intervals. Survey-adjusted logistic regression models were fit to assess the association between obstructive sleep apnea and mechanical ventilation or tracheostomy, acute respiratory distress syndrome, hypertensive disorders of pregnancy, peripartum hysterectomy, pulmonary edema/heart failure, stillbirth, and preterm birth.
Results:
From 2000 to 2019, an estimated 76,753,013 delivery hospitalizations were identified, of which 54,238 (0.07%) had a diagnosis of obstructive sleep apnea. During the study period, the presence of obstructive sleep apnea during delivery hospitalizations increased from 0.4 to 20.5 cases per 10,000 delivery hospitalizations (average annual percentage change, 20.6%; 95% confidence interval, 19.1-22.2). Clinical factors associated with obstructive sleep apnea included obesity (4.3% of women without and 57.7% with obstructive sleep apnea), asthma (3.2% of women without and 25.3% with obstructive sleep apnea), chronic hypertension (2.0% of women without and 24.5% with obstructive sleep apnea), and pregestational diabetes mellitus (0.9% of women without and 10.9% with obstructive sleep apnea). In adjusted analyses accounting for obesity, other clinical factors, demographics, and hospital characteristics, obstructive sleep apnea was associated with increased odds of mechanical ventilation or tracheostomy (adjusted odds ratio, 21.9; 95% confidence interval, 18.0-26.7), acute respiratory distress syndrome (adjusted odds ratio, 5.9; 95% confidence interval, 5.4-6.5), hypertensive disorders of pregnancy (adjusted odds ratio, 1.6; 95% confidence interval, 1.6-1.7), stillbirth (adjusted odds ratio, 1.2; 95% confidence interval, 1.0-1.4), pulmonary edema/heart failure (adjusted odds ratio, 3.7; 95% confidence interval, 2.9-4.7), peripartum hysterectomy (adjusted odds ratio, 1.66; 95% confidence interval, 1.23-2.23), and preterm birth (adjusted odds ratio, 1.2; 95% confidence interval, 1.1-1.2).
Conclusion:
Obstructive sleep apnea diagnoses are increasingly common in the obstetrical population and are associated with a range of adverse obstetrical outcomes during delivery hospitalizations.
Background:
Obstructive sleep apnea (OSA) is closely related to maternal obesity in pregnant women, and the association increases with later pregnancy. Obesity and OSA are risk factors of pregnancy-related complications, including gestational hypertension, gestational diabetes mellitus (GDM), and fetal morbidities. We aimed to determine the prevalence of OSA and to assess the impact of OSA on pregnancy-related disorders in overweight pregnant women.
Methods:
Eligible participants who were overweight [body mass index (BMI) ≥ 23 kg/m²] in gestational age 30 weeks or more, assessed OSA using a portable polysomnography at home. Clinical data were collected from pregnant women and their babies.
Results:
The average age of 51 participants was 34.5 years (27-44 years). The number of primipara was 25 (49%) and that of multipara was 26 (51%). Eight cases of GDM (15.7%) and five cases of preeclampsia (9.8%) were reported, and six patients (11.8%) experienced preterm delivery. In results of polysomnography, 14 patients (27.5%) were diagnosed as OSA. Apnea-hypopnea index moderately correlated with BMI (r = 0.515, P < 0.001). The BMI (P < 0.005) and preeclampsia rate (P < 0.017) were higher in the OSA group compared to the control group. Odds ratios (ORs) adjusting age, BMI, parity, and abortion history were calculated. The presence of OSA increased OR of preeclampsia (OR, 13.1; 95% confidence interval, 1.1-171.3). The majority of preeclampsia patients (4/5, 80%) underwent preterm delivery.
Conclusion:
OSA is an important risk factor for preeclampsia, resulting in preterm delivery. For overweight pregnant women, an OSA evaluation should be mandatory.
Background:
Previous studies of obstructive sleep apnea (OSA) risk in gravidas with chronic hypertension (cHTN) did not control for obesity as a risk factor for OSA. We therefore performed this study to evaluate whether OSA is more prevalent among gravidas with cHTN compared to normotensive gravidas matched for body mass index (BMI) and gestational age (primary outcome). We also assessed whether OSA is more severe when comorbid with cHTN in pregnancy (secondary outcome).
Methods:
This was a single-center, prospective cohort study. Adult gravidas at 10-20 weeks of gestation, with and without cHTN, were enrolled and BMI matched. All subjects answered OSA screening questionnaires and underwent a home sleep test when they were between 10 and 20 weeks of gestation. Pregnancy outcomes were followed for all subjects. We performed univariable and multivariable logistic regression to model the relationship between cHTN status and OSA.
Results:
A total of 100 pregnant subjects (50 with cHTN and 50 normotensive) completed a home sleep test of 2 hours or more. There were no differences in demographic variables between the 2 groups, except that gravidas with cHTN were significantly older than normotensive subjects (mean ± standard deviation [SD] 34 ± 4 vs 30 ± 6 years; P < .001). OSA was more prevalent (64% vs 38%; P = .009; odds ratio [95% confidence interval (CI)] 2.90 [1.30-6.65]; P = .01) and more severe in gravidas with cHTN (moderate or severe OSA 59% vs 21%; P = .009). After controlling for age, we found no overall association between cHTN on OSA risk (adjusted odds ratio [95% CI] 2.22 [0.92-5.40]; P = .076). However, among gravidas older than 25 years of age, cHTN was associated with higher odds of OSA (adjusted odds ratio [95% CI], 2.64 [1.06-6.71], P = .038).
Conclusions:
cHTN and age are important risk factors for OSA in gravidas. Gravidas with cHTN should be screened for OSA in early pregnancy. Future studies may validate screening tools that include cHTN and age, and investigate the role of OSA therapy in blood pressure control.
Objective
Obstructive sleep apnea (OSA) may exacerbate the widespread endothelial dysfunction seen in preeclampsia, potentially worsening clinical outcomes. We aimed to assess whether OSA is associated with an increased risk of severe maternal morbidity, cardiovascular morbidity, and healthcare utilization among women with preeclampsia.
Study Design
We performed a retrospective cohort study utilizing data from the National Perinatal Information Center (2010-2014) in the United States. The cohort comprised women with preeclampsia. We estimated the association between OSA and the outcomes using logistic regression analyses and determined odds ratio adjusted for demographic factors and comorbidities (ORadj) and associated 95% confidence intervals (CI).
Main outcome measures
The primary outcome was a composite of mortality and severe maternal morbidity comprising intensive care unit (ICU) admission, acute renal failure, pulmonary edema, pulmonary embolism, congestive heart failure, cardiomyopathy, and stroke. Secondary outcomes comprised the subset of cardiovascular events, as well as increased healthcare utilization (including Cesarean delivery, preterm birth, ICU admission, and prolonged length of hospital stay).
Results
In total, 71,159 women had preeclampsia, including 270 (0.4%) with OSA. Women with preeclampsia and OSA were more likely to experience severe maternal morbidity than women without OSA (ORadj 2.65, 95% CI [1.94-3.61]). Moreover, women with concomitant OSA had more severe cardiovascular morbidity than women without OSA (ORadj 5.05, 95% CI [2.28-11.17]). Accordingly, OSA was associated with increased healthcare utilization in women with preeclampsia (ORadj. 2.26, 95% CI [1.45-3.52]).
Conclusion
In women with preeclampsia, OSA increases the risk for severe maternal morbidity, cardiovascular morbidity, and healthcare utilization.
Running Head: OSA, preeclampsia and maternal morbidity
There is now ample evidence that differences in sex and gender contribute to the incidence, susceptibility, presentation, diagnosis, and clinical course of many lung diseases. Some conditions are more prevalent in females, such as pulmonary arterial hypertension (PAH) and sarcoidosis. Some life stages -such as pregnancy- are unique to females and can affect the onset and course of lung disease. Clinical presentation may differ as well, such as higher number of exacerbations experienced by women with cystic fibrosis (CF), more fatigue in women with sarcoidosis, and more difficulty in achieving smoking cessation. Outcomes such as mortality may be different as well, as noted by higher mortality in females with CF. In addition, response to therapy and medication safety may also differ by sex, and yet, pharmacogenomic factors are often not adequately addressed in clinical trials. Various aspects of lung/sleep biology and pathobiology are impacted by female sex and female reproductive transitions. Differential gene expression or organ development can be impacted by these biologic differences. Understanding these differences is the first step in moving towards precision medicine for all patients.. This article is the second part of a state-of-the-art review of specific effects of sex and gender focused on epidemiology, disease presentation, risk factors and management of selected lung diseases. We review the recent literature and focus on recent guidelines incorporating sex and gender differences in pulmonary hypertension, cystic fibrosis (CF) and non-CF bronchiectasis, sarcoidosis, restless legs syndrome (RLS) and insomnia, and critical illness. We also provide a brief summary on effects of pregnancy on lung diseases and discuss impact of sex and gender on tobacco use and treatment of nicotine use disorder.
Background:
Evaluation and interpretation of the literature on obstructive sleep apnea is needed to consolidate and summarize key factors important for clinical management of the OSA adult patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).
Methods:
Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.
Results:
The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA and treatment on the multiple comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.
Conclusion:
This review of the literature in OSA consolidates the available knowledge and identifies the limitations of the current evidence. This effort aims to highlight the basis of OSA evidence-based practice and identify future research needs. Knowledge gaps and opportunities for improvement include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy. This article is protected by copyright. All rights reserved.
Sleep-related breathing disorders (SDB) in pregnant women occurs in up to 30% of pregnancies. The coincidence has been and still is a relatively neglected topic in sleep medicine and especially in the clinical routine in obstetrics; nevertheless, the coincidence of SDB and pregnancy represents a substantial risk for both the mother and the unborn child. With respect to adverse pregnancy outcomes, pregnant women have an increased risk of gestational hypertension, gestational diabetes, preeclampsia and eclampsia, an increased rate of cesarean sections and an increased maternal mortality. With respect to the children the predominant risks are miscarriage, premature birth and in rare cases stillbirth, retarded intrauterine growth and postpartum developmental disorders in the first 6 years. Continuous positive airway pressure (CPAP) treatment is the gold standard also in pregnant women. Only a few studies on CPAP treatment with small patient collectives are available in the literature; however, they uniformly show the positive effect of CPAP with respect to the abovementioned factors with no negative influences on the course of pregnancy. For both sleep specialists and particularly obstetricians there is a need to raise awareness with respect to the topic of SDB and pregnancy.
Background
Persons with preeclampsia are at increased short-term risk of adverse cardiovascular outcomes during pregnancy and the early postpartum period. We aimed to develop and internally validate a risk assessment tool to predict acute cardiovascular morbidity in preeclampsia.
Methods
The study was conducted at an academic obstetric hospital. Participants with preeclampsia at delivery between 2007 and 2017 were included. A model to predict acute cardiovascular morbidity at delivery and within 6 weeks postpartum was developed and evaluated. The primary composite outcome included pulmonary edema/acute heart failure, myocardial infarction, aneurysm, cardiac arrest/ventricular fibrillation, heart failure/arrest during surgery or procedure, cerebrovascular disorders, cardiogenic shock, conversion of cardiac rhythm, and difficult-to-control severe hypertension. We assessed model discrimination and calibration. We used bootstrapping for internal validation.
Results
4,171 participants with preeclampsia were included. The final model comprised 8 variables. Predictors positively associated with acute cardiovascular morbidity (presented as odds ratio [OR] with 95% confidence interval [CI]) were: gestational age at delivery (20-36 weeks 5.36 [3.67, 7.82]; 37-38 weeks 1.75 [1.16, 2.64]), maternal age (≥40 years 1.65 [1.00, 2.72]; 35-39 years 1.49 [1.07, 2.09]), and prior cesarean delivery (1.47, [1.01, 2.13]). The model had an area under the receiver operating characteristic curve of 0.72 (95% CI [0.69, 0.74]). Moreover, it was adequately calibrated and performed well on internal validation.
Conclusions
This risk prediction tool identified women with preeclampsia at highest risk of acute cardiovascular morbidity. If externally validated, this tool may facilitate early interventions aimed at preventing adverse cardiovascular outcomes in pregnancy and postpartum.
During pregnancy, a life stage during which there are significant hormonal, anatomic, physiological, and psychological changes, women experience unique challenges with sleep. Pregnancy can exacerbate preexisting sleep problems as well as cause the emergence of new ones. The impact of sleep deficiency – which includes insufficient sleep, poorly timed sleep, and clinical sleep disorders – is observed not only on the individual but also on the offspring, with potentially long-lasting implications.KeywordsPittsburgh Sleep Quality Index (PSQI)Unrefreshed sleepSleep in mid-pregnancySleep-disordered breathing (SDB)RLS during pregnancyInsufficient Sleep
Objective:
To estimate whether sleep-disordered breathing during pregnancy is a risk factor for the development of hypertensive disorders of pregnancy and gestational diabetes mellitus (GDM).
Methods:
In this prospective cohort study, nulliparous women underwent in-home sleep-disordered breathing assessments in early (6-15 weeks of gestation) and midpregnancy (22-31 weeks of gestation). Participants and health care providers were blinded to the sleep test results. An apnea-hypopnea index of 5 or greater was used to define sleep-disordered breathing. Exposure-response relationships were examined, grouping participants into four apnea-hypopnea index groups: 0, greater than 0 to less than 5, 5 to less than 15, and 15 or greater. The study was powered to test the primary hypothesis that sleep-disordered breathing occurring in pregnancy is associated with an increased incidence of preeclampsia. Secondary outcomes were rates of hypertensive disorders of pregnancy, defined as preeclampsia and antepartum gestational hypertension, and GDM. Crude and adjusted odds ratios and 95% confidence intervals (CIs) were calculated from univariate and multivariate logistic regression models.
Results:
Three thousand seven hundred five women were enrolled. Apnea-hypopnea index data were available for 3,132 (84.5%) and 2,474 (66.8%) women in early and midpregnancy, respectively. The corresponding prevalence of sleep-disordered breathing was 3.6% and 8.3%. The prevalence of preeclampsia was 6.0%, hypertensive disorders of pregnancy 13.1%, and GDM 4.1%. In early and midpregnancy the adjusted odds ratios for preeclampsia when sleep-disordered breathing was present were 1.94 (95% CI 1.07-3.51) and 1.95 (95% CI 1.18-3.23), respectively; hypertensive disorders of pregnancy 1.46 (95% CI 0.91-2.32) and 1.73 (95% CI 1.19-2.52); and GDM 3.47 (95% CI 1.95-6.19) and 2.79 (95% CI 1.63-4.77). Increasing exposure-response relationships were observed between apnea-hypopnea index and both hypertensive disorders and GDM.
Conclusion:
There is an independent association between sleep-disordered breathing and preeclampsia, hypertensive disorders of pregnancy, and GDM.
Study objectives:
To examine the association between sleep apnea and pregnancy outcomes in a large population-based cohort.
Methods:
Population-based cohort study using linked birth and hospital records was conducted in New South Wales, Australia. Participants were all women who gave birth in hospital from 2002 to 2012 (N = 636,227). Sleep apnea in the year before pregnancy or during pregnancy was identified from hospital records. Outcomes of interest were gestational diabetes, pregnancy hypertension, planned delivery, caesarean section, preterm birth, perinatal death, 5-minute Apgar score, admission to neonatal intensive care or special care nursery, and infant size for gestational age. Maternal outcomes were identified using a combination of hospital and birth records. Infant outcomes came from the birth record. Modified Poisson regression models were used to examine associations between sleep apnea and each outcome taking into account maternal age, country of birth, socioeconomic disadvantage, smoking, obesity, parity, pre-existing diabetes and hypertension.
Results:
Sleep apnea was significantly associated with pregnancy hypertension (adjusted RR 1.40; 95% CI 1.15-1.70), planned delivery (1.15; 1.07-1.23), preterm birth (1.50; 1.21-1.84), 5-minute Apgar <7 (1.60; 1.07-2.38), admission to neonatal intensive care/special care nursery (1.26; 1.11-1.44), large-for-gestational-age infants (1.27; 1.04-1.55) but not with gestational diabetes (1.09; 0.82-1.46), caesarean section (1.06; 0.96-1.17), perinatal death (1.73; 0.92-3.25), or small-for-gestational-age infants (0.81; 0.61-1.08).
Conclusions:
Sleep apnea is associated with higher rates of obstetric complications and intervention, as well as preterm delivery. Future research should examine if these are independent of obstetric history.
Sleep disordered breathing has been linked to adverse cardiovascular outcomes in the general population. In pregnancy, sleep disordered breathing has also been linked to pathologic disorders that have been associated with long term cardiovascular and metabolic outcomes such as gestational hypertensive disorders and gestational diabetes mellitus. Endothelial dysfunction, sympathetic stimulation and inflammation are among the mechanisms proposed to explain the association with adverse outcomes. In addition to mechanistic research, future efforts need to focus on the effect of therapy on such outcomes.
OBJECTIVE
Recently, sleep-disordered breathing (SDB) has been reported to be associated with the development of gestational diabetes mellitus (GDM). Accordingly, as this is emergent area of research that has significant clinical relevance, the objective of this meta-analysis is to examine the relationship between SDB with GDM.RESEARCH DESIGN AND METHODS
We searched several electronic databases for all of the studies published before January 2013 and reviewed references of published articles. Meta-analytic procedures were used to estimate the unadjusted and BMI-adjusted odds ratios (ORs) using a random effects model. Significant values, weighted effect sizes, and 95% CIs were calculated, and tests of homogeneity of variance were performed.RESULTSResults from nine independent studies with a total of 9,795 pregnant women showed that SDB was significantly associated with an increased risk of GDM. Women with SDB had a more than threefold increased risk of GDM, with a pooled BMI-adjusted OR 3.06 (95% CI 1.89-4.96).CONCLUSIONS
These findings demonstrate a significant association between SDB and GDM that is evident even after considered confounding by obesity. This meta-analysis indicates a need to evaluate the role of early recognition and treatment of SDB early during pregnancy.
Context:
Questionnaire studies linked symptoms of obstructive sleep apnea (OSA) to the risk of gestational diabetes mellitus (GDM). Whether this association is present when OSA is assessed objectively by polysomnography is not known.
Objective:
The objective of the study was to assess the relationship between pregnancy, OSA, and GDM.
Design, setting, and participants:
We conducted observational case-control studies using polysomnography in 15 nonpregnant, nondiabetic women (NP-NGT), 15 pregnant women with normal glucose tolerance (P-NGT), and 15 pregnant women with GDM (P-GDM). The groups were frequency matched for age and race/ethnicity. Pregnant women were studied during the late second to early third trimester.
Main outcome measures:
Comparisons of OSA diagnosis and sleep parameters between NP-NGT and P-NGT to assess the impact of pregnancy and between P-NGT and P-GDM to explore the association between GDM and OSA were measured.
Results:
Compared with NP-NGT, P-NGT women had a higher apnea hypopnea index (AHI) (median 2.0 vs 0.5, P = .03) and more disrupted sleep as reflected by a higher wake time after sleep onset (median 66 vs 21 min, P < .01) and a higher microarousal index (median 16.4 vs 10.6, P = .01). Among the pregnant women, P-GDM had markedly lower total sleep time (median 397 vs 464 min, P = .02) and a higher AHI (median 8.2 vs 2.0, P = .05) than P-NGT women. OSA was more prevalent in P-GDM than in P-NGT women (73% vs 27%, P = .01). After adjustment for prepregnancy body mass index, the diagnosis of GDM was associated with a diagnosis of OSA [odds ratio 6.60 (95% confidence interval 1.15-37.96)]. In pregnancy, after adjusting for prepregnancy body mass index, higher microarousal index significantly associated with higher hemoglobin A1c and fasting glucose levels. Higher oxygen desaturation index was associated with higher fasting glucose levels.
Conclusion:
Pregnancy is associated with sleep disturbances. Sleep is more disturbed in GDM than in P-NGT women. There is a strong association between GDM and OSA.
Screening for sleep disordered breathing (SDB) remains poor in the general population, despite evidence for association with adverse outcomes and improvement of certain outcomes with therapy. Data from the past decade have suggested an association between snoring and adverse pregnancy outcomes including gestational hypertensive disorders. However, it is unclear how often SDB is screened for in pregnancy. The objective of this study was to evaluate whether, and how, symptoms of SDB are assessed during prenatal care.
This study was designed as a survey-based observational study. Within 48 hours of delivery, English-speaking patients were surveyed regarding prenatal conversations with obstetric providers about symptoms of SDB. During a similar time period, obstetric providers completed an anonymous questionnaire regarding how often they discussed the same symptoms during prenatal visits.
A total of 776 patients and 80 providers performing the majority of deliveries at the same hospital answered the survey. Nurse providers asked about sleep quality significantly more often than physician providers; however, responses to questions about snoring were similar in both groups. Resident physicians were the least likely to ask about sleep quality. Less than 3% of providers reported asking about snoring, closely matching patient responses. A total of 44% of patients surveyed were overweight and 21.7% were obese. Although 32% of patients snored, only 5% were asked about snoring during a prenatal visit. Obese women and women with a history of gestational hypertensive disorders were more likely to report being asked about snoring.
Based on patient and obstetric provider recollections of discussions, the issue of SDB is poorly assessed during routine prenatal care, despite an increasing prevalence of overweight and obesity in the pregnant population.
Although obesity screening and treatment are recommended by the US Preventive Services Task Force, 1 in 5 women are obese when they conceive. Women are at risk for complications of untreated obesity particularly during the reproductive years and may benefit from targeted screening. Risks of obesity and potential benefits of intervention in this population are well characterized. Rates of adverse pregnancy outcomes including gestational diabetes, preeclampsia, cesarean delivery, and stillbirth increase as maternal body mass index increases. Offspring risks include higher rates of congenital anomalies, abnormal intrauterine growth, and childhood obesity. Observational data suggest that weight loss may reduce risks of obesity-related pregnancy complications. Although obesity screening has not been studied in women of reproductive age, the effect of obesity and the potential for significant maternal and fetal benefits make screening of women during the childbearing years an essential part of the effort to reduce the impact of the obesity epidemic.
The physiological changes of pregnancy may predispose females to develop sleep-disordered breathing (SDB) or protect against it. Studies evaluating outcomes of SDB symptoms in pregnancy are scarce. The goal of this study was to evaluate the prevalence of SDB symptoms in pregnancy and their relationship with pregnancy and neonatal outcomes.
A cross-sectional survey of randomly selected immediate postpartum females was performed using the multivariable apnoea prediction index. Record review, including demographics and medical history, was performed. Main outcome measures included pregnancy and neonatal outcomes.
1,000 subjects were recruited. Mean± sd age was 29.1±6.1 yrs. Factors used in the regression analysis included age, body mass index, diabetes, chronic hypertension, multifetal gestations, smoking and renal disease. Snoring was present in 35.1% of subjects. Symptoms of SDB were associated with a higher likelihood of pregnancy-induced hypertension and pre-eclampsia (adjusted OR 2.3, 95% CI 1.4–4.0), gestational diabetes (adjusted OR 2.1, 95% CI 1.3–3.4) and unplanned Caesarean deliveries (adjusted OR 2.1, 95% CI 1.4–3.2) after multivariable regression analysis. Gasping may have been associated with a higher likelihood of preterm delivery, after adjusting for age and multifetal pregnancies (adjusted OR 1.8, 95% CI 1.1–3.2) but this association appeared to be mediated by pre-eclampsia.
Symptoms of SDB are common in pregnancy and associated with a higher likelihood of gestational hypertensive disorders, gestational diabetes and unplanned Caesarean deliveries.
To assess the risk factors for the presence and severity of obstructive sleep apnea (OSA) among obese patients with type 2 diabetes.
Unattended polysomnography was performed in 306 participants.
Over 86% of participants had OSA with an apnea-hypopnea index (AHI) >or=5 events/h. The mean AHI was 20.5 +/- 16.8 events/h. A total of 30.5% of the participants had moderate OSA (15 <or= AHI <30), and 22.6% had severe OSA (AHI >or=30). Waist circumference (odds ratio 1.1; 95% CI 1.0-1.1; P = 0.03) was significantly related to the presence of OSA. Severe OSA was most likely in individuals with a higher BMI (odds ratio 1.1; 95% CI 1.0-1.2; P = 0.03).
Physicians should be particularly cognizant of the likelihood of OSA in obese patients with type 2 diabetes, especially among individuals with higher waist circumference and BMI.
Women who develop pre-eclampsia in pregnancy are at increased risk of cardiovascular disease. The offspring from pregnancies complicated by pre-eclampsia have higher blood pressures during childhood, but little is known about their long-term health. We hypothesized that pre-eclampsia would lead to an increased risk of cardiovascular disease in the offspring.
We traced 6410 babies born in Helsinki, Finland, from 1934 to 1944. We used the mothers' blood pressure levels and the presence of proteinuria during pregnancy to define pre-eclampsia and gestational hypertension without proteinuria according to modern criteria.
Two hundred eighty-four of the pregnancies were complicated by pre-eclampsia (120 with nonsevere and 164 with severe disease) and 1592 by gestational hypertension. The crude hazard ratio for all forms of stroke among people whose mothers had pre-eclampsia was 1.9 (1.2 to 3.0; P=0.01); among people whose mothers had gestational hypertension, it was 1.4 (1.0 to 1.8; P=0.03). There was no evidence that these pregnancy disorders were associated with coronary heart disease in the offspring. Pre-eclampsia, in particular severe disease, was associated with a reduced mean head circumference at birth, whereas gestational hypertension was associated with an increased head circumference in relation to body length.
People born after pregnancies complicated by pre-eclampsia or gestational hypertension are at increased risk of stroke. The underlying processes may include a local disorder of the blood vessels of the brain as a consequence of either reduced brain growth or impaired brain growth leading to "brain-sparing" responses in utero.
Cross-sectional epidemiologic studies show an association between sleep-disordered breathing and hypertension, but only one cohort study has examined sleep-disordered breathing as a risk factor for incident hypertension.
To examine whether sleep-disordered breathing increases the risk of incident hypertension among persons 40 years of age and older.
In a prospective cohort study, we analyzed data from 2,470 participants who at baseline did not have hypertension, defined as blood pressure of at least 140/90 mm Hg or taking antihypertensive medication. The apnea-hypopnea index (AHI), the number of apneas plus hypopneas per hour of sleep, was measured by overnight in-home polysomnography. We estimated odds ratios for developing hypertension during 5 years of follow-up according to baseline AHI.
The odds ratios for incident hypertension increased with increasing baseline AHI; however, this relationship was attenuated and not statistically significant after adjustment for baseline body-mass index. Although not statistically significant, the observed association between a baseline AHI greater than 30 and future hypertension (odds ratio, 1.51; 95% confidence interval, 0.93-2.47) does not exclude the possibility of a modest association.
Among middle-aged and older persons without hypertension, much of the relationship between AHI and risk of incident hypertension was accounted for by obesity. After adjustment for body mass index, the AHI was not a significant predictor of future hypertension, although a modest influence of an AHI greater than 30 on hypertension could not be excluded.
Sleep-disordered breathing is prevalent in the general population and has been linked to chronically elevated blood pressure in cross-sectional epidemiologic studies. We performed a prospective, population-based study of the association between objectively measured sleep-disordered breathing and hypertension (defined as a laboratory-measured blood pressure of at least 140/90 mm Hg or the use of antihypertensive medications).
We analyzed data on sleep-disordered breathing, blood pressure, habitus, and health history at base line and after four years of follow-up in 709 participants of the Wisconsin Sleep Cohort Study (and after eight years of follow-up in the case of 184 of these participants). Participants were assessed overnight by 18-channel polysomnography for sleep-disordered breathing, as defined by the apnea-hypopnea index (the number of episodes of apnea and hypopnea per hour of sleep). The odds ratios for the presence of hypertension at the four-year follow-up study according to the apnea-hypopnea index at base line were estimated after adjustment for base-line hypertension status, body-mass index, neck and waist circumference, age, sex, and weekly use of alcohol and cigarettes.
Relative to the reference category of an apnea-hypopnea index of 0 events per hour at base line, the odds ratios for the presence of hypertension at follow-up were 1.42 (95 percent confidence interval, 1.13 to 1.78) with an apnea-hypopnea index of 0.1 to 4.9 events per hour at base line as compared with none, 2.03 (95 percent confidence interval, 1.29 to 3.17) with an apnea-hypopnea index of 5.0 to 14.9 events per hour, and 2.89 (95 percent confidence interval, 1.46 to 5.64) with an apnea-hypopnea index of 15.0 or more events per hour.
We found a dose-response association between sleep-disordered breathing at base line and the presence of hypertension four years later that was independent of known confounding factors. The findings suggest that sleep-disordered breathing is likely to be a risk factor for hypertension and consequent cardiovascular morbidity in the general population.
Sleep-disordered breathing recurrent intermittent hypoxia and sympathetic nervous system activity surges provide the milieu for cardiac arrhythmia development.
We postulate that the prevalence of nocturnal cardiac arrhythmias is higher among subjects with than without sleep-disordered breathing.
The prevalence of arrhythmias was compared in two samples of participants from the Sleep Heart Health Study frequency-matched on age, sex, race/ethnicity, and body mass index: (1) 228 subjects with sleep-disordered breathing (respiratory disturbance index>or=30) and (2) 338 subjects without sleep-disordered breathing (respiratory disturbance index<5).
Atrial fibrillation, nonsustained ventricular tachycardia, and complex ventricular ectopy (nonsustained ventricular tachycardia or bigeminy or trigeminy or quadrigeminy) were more common in subjects with sleep-disordered breathing compared with those without sleep-disordered breathing: 4.8 versus 0.9% (p=0.003) for atrial fibrillation; 5.3 versus 1.2% (p=0.004) for nonsustained ventricular tachycardia; 25.0 versus 14.5% (p=0.002) for complex ventricular ectopy. Compared with those without sleep-disordered breathing and adjusting for age, sex, body mass index, and prevalent coronary heart disease, individuals with sleep-disordered breathing had four times the odds of atrial fibrillation (odds ratio [OR], 4.02; 95% confidence interval [CI], 1.03-15.74), three times the odds of nonsustained ventricular tachycardia (OR, 3.40; 95% CI, 1.03-11.20), and almost twice the odds of complex ventricular ectopy (OR, 1.74; 95% CI, 1.11-2.74). A significant relation was also observed between sleep-disordered breathing and ventricular ectopic beats/h (p<0.0003) considered as a continuous outcome.
Individuals with severe sleep-disordered breathing have two- to fourfold higher odds of complex arrhythmias than those without sleep-disordered breathing even after adjustment for potential confounders.
Management of preeclampsia often culminates in induced delivery of a very preterm infant. While early termination protects the fetus from an intrauterine death, the newborn then faces increased risks associated with preterm delivery. This practice has increased in recent decades, but its net effect on fetal and infant survival has not been assessed.
To assess the effect on fetal and infant survival of increased rates of early delivery of preeclamptic pregnancies.
Population-based observational longitudinal study using registry data from 804 448 singleton first-born infants with Norwegian-born mothers and registered in the Medical Birth Registry of Norway between 1967 and 2003.
Odds ratio (OR) of fetal and early childhood death in relation to preeclampsia.
Among preeclamptic pregnancies, inductions before 37 weeks increased from 8% in 1967-1978 to nearly 20% in 1991-2003. During this period, the adjusted OR for stillbirth decreased from 4.2 (95% confidence interval [CI], 3.8-4.7) to 1.3 (95% CI, 1.1-1.7) for preeclamptic compared with nonpreeclamptic pregnancies. During the same period, the OR for neonatal death after preeclamptic pregnancy remained relatively stable (1.7 in 1967-1978 vs 2.0 in 1991-2003). Later infant and childhood mortality also showed little change.
Fetal survival in preeclamptic pregnancies has vastly improved over the past 35 years in Norway, presumably because of more aggressive clinical management. However, the relative risk of neonatal death following a preeclamptic pregnancy has not changed over time.
Sleep disordered breathing (SDB) represents a spectrum of disorders, including habitual snoring and obstructive sleep apnea (OSA). SDB is characterized by chronic intermittent hypoxia, airflow limitation and recurrent arousals, which may lead to tissue hypoperfusion, hypoxia and inflammation. In this study, we aimed to examine whether SDB during pregnancy was associated with histopathologic evidence of chronic placental hypoxia and/or uteroplacental underperfusion. The placentas of women with OSA (n=23), habitual snoring (n=78) and non-snorer controls (n=47) were assessed for histopathologic and immunohistochemical markers of chronic hypoxia and uteroplacental underperfusion. Fetal normoblastemia was significantly more prevalent in SDB placentas than in those of non-snorer controls (34.6% and 56.5% in snorers and OSA, respectively, versus 6.4% in controls). Expression of the tissue hypoxia marker carbonic anhydrase IX (CAIX) was more common in OSA placentas than controls (81.5% and 91.3% in snorers and OSA, respectively, versus 57.5% in controls). Adjusting for confounders such as body mass index, diabetes mellitus or chronic hypertension did not alter the results. The uteroplacental underperfusion scores were similar between the three groups. Our findings suggest that SDB during pregnancy is associated with fetoplacental hypoxia, as manifested by fetal normoblastemia and increased placental CAIX immunoreactivity. The clinical implications and underlying mechanisms remain to be determined.
Health administrative (HA) databases are increasingly used to identify surgical patients with obstructive sleep apnea (OSA) for research purposes, primarily using diagnostic codes. Such means to identify patients with OSA are not validated. The authors determined the accuracy of case-ascertainment algorithms for identifying patients with OSA with the use of HA data.
Clinical data derived from an academic health sciences network within a universal health insurance plan were used as the reference standard. The authors linked patients to HA data and retrieved all claims in the 2 yr before surgery to determine the presence of any diagnostic codes, diagnostic procedures, or therapeutic interventions consistent with OSA.
The authors identified 4,965 patients (2003 to 2012) who underwent preoperative polysomnogram. Of these, 4,353 patients were linked to HA data; 2,427 of these (56%) had OSA based on diagnosis by a sleep physician or the apnea hypopnea index. A claim for a polysomnogram and receipt of a positive airway pressure device had a sensitivity, specificity, and positive likelihood ratio (+LR) for OSA of 19, 98, and 10.9%, respectively. An International Classification of Diseases, Tenth Revision, code for sleep apnea in hospitalization abstracts was 9% sensitive and 98% specific (+LR, 4.5). A physician billing claim for OSA (International Classification of Diseases, Ninth Revision, 780.5) was 58% sensitive and 38% specific (+LR, 0.9). A polysomnogram and a positive airway pressure device or any code for OSA was 70% sensitive and 36% specific (+LR, 1.1).
No code or combination of codes provided a +LR high enough to adequately identify patients with OSA. Existing studies using administrative codes to identify OSA should be interpreted with caution.
Obstructive sleep apnea (OSA) is a common disorder affecting between 5% and 24% of men and women. The prevalence of OSA in the intensive care unit (ICU) population is unknown. This study was undertaken to determine the prevalence of OSA in patients admitted to the ICU and to determine if OSA is an independent predictor of mortality.
This is a retrospective study using an Acute Physiology and Chronic Health Evaluation III database cross-referenced to a comprehensive clinical database to identify patients with and without OSA admitted to medical, surgical, and mixed ICUs at a large academic medical center.
Between January 2003 and December 2005, 15077 patients were admitted to the ICUs; and of these, 1183 (7.8%) had a physician-documented diagnosis of OSA. Eight hundred thirty-five (71%) patients had polysomnographic testing at our institution with a documented apnea-hypopnea index more than 5 per hour. Patients with OSA were younger (59.1 ± 14.0 vs 62.3 ± 18.0), male (58.9% vs 53.7%), and had lower Acute Physiology and Chronic Health Evaluation III scores (45.3 ± 24.1 vs 54.9 ± 27.7). Predicted mortality (10.3% ± 16.4% vs16.3 ± 21.7), median ICU length of stay (1.13 vs 1.50 days), ICU mortality (2.4% vs 6.2%), and hospital mortality (3.9% vs 11.4%) were all reduced in patients with OSA, P values < .001. When adjusted for the severity of illness, OSA was independently associated with decreased hospital mortality, (0.408; 95% confidence interval, 0.298-0.557).
Obstructive sleep apnea is common in patients admitted to the ICU. Obstructive sleep apnea was associated with a reduction in both ICU and hospital mortality.
Copyright © 2014 Elsevier Inc. All rights reserved.
Obstructive sleep apnea (OSA) is associated with placenta-mediated adverse clinical outcomes. We aimed at comparing placenta-secreted proteins, such as first and second trimester Down syndrome screening markers which have been linked to preeclampsia, and markers of angiogenesis in pregnant women with OSA, and pregnant controls at low risk for OSA.
A case-control study of pregnant women with OSA and controls at low risk for OSA was performed. Levels of first and second trimester markers were reported as multiple of median (MoM), and adjusted for body mass index (BMI). Stored samples were tested for markers of angiogenesis and adjusted for gestational age, BMI, and chronic hypertension.
A total of 24 women with OSA and 166 controls had screening markers. BMI was higher in cases compared to controls, P=0.01. MoM levels of placenta associated plasma protein-A (PAPP-A) were significantly lower in cases versus controls, even after adjusting for BMI (0.52 IQR 0.48 vs. 1.01 IQR 0.63, P=0.009). The ratio of soluble vascular endothelial growth factor receptor 1 to placental growth factor was significantly higher in cases than controls, even after adjusting for confounders (4.42 IQR 2.52 vs. 2.93 IQR 2.01, P=0.009).
Circulating placenta-secreted glycoproteins and markers of angiogenesis are altered in pregnant women with OSA.
A recent trend in increasing rates of severe maternal morbidity and mortality despite quality improvements has been noted. The goal of this study is to estimate the national prevalence of obstructive sleep apnea (OSA) in pregnant women and examine associations between OSA and pregnancy-related morbidities, including in-hospital maternal mortality.
A retrospective, cross-sectional analysis.
A nationally representative sample of maternal hospital discharges from 1998-2009.
The analytic sample included 55,781,965 pregnancy-related inpatient hospital discharges.
N/A.
The Nationwide Inpatient Sample (NIS) database was used to identify hospital stays for women who were pregnant or gave birth. Among these women, we determined length of hospital stay, in-hospital mortality, and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify OSA and other outcome measures. Multivariable logistic regression modeling was used to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI) for the associations between OSA and each outcome. The overall rate of OSA was 3.0 per 10,000; however, the rate climbed substantially from 0.7 in 1998 to 7.3 in 2009, with an average annual increase of 24%. After controlling for obesity and other potential confounders, OSA was associated with increased odds of pregnancy-related morbidities including preeclampsia (OR, 2.5; 95% CI, 2.2-2.9), eclampsia (OR, 5.4; 95% CI, 3.3-8.9), cardiomyopathy (OR, 9.0; 95% CI, 7.5-10.9), and pulmonary embolism (OR, 4.5; 95% CI, 2.3-8.9). Women with OSA experienced a more than fivefold increased odds of in-hospital mortality (95% CI, 2.4-11.5). The adverse effects of OSA on selected outcomes were exacerbated by obesity.
Obstructive sleep apnea is associated with severe maternal morbidity, cardiovascular morbidity, and in-hospital death. Targeted interventions may improve pregnancy outcomes in this group.
Louis JM, Mogos MF, Salemi JL, Redline S, Salihu HM. Obstructive sleep apnea and severe maternal-infant morbidity/mortality in the United States, 1998-2009. SLEEP 2014;37(5):843-849.
Abstract Background: Obstructive sleep apnea (OSA) has been associated with adverse fetal outcomes in some studies. Second trimester Down syndrome screening markers reflect fetal and fetoplacental wellbeing. We aimed to compare markers of fetal and feto-placental wellbeing in women with OSA and low risk controls. Methods: A retrospective case-control study of pregnant women with OSA and available second trimester markers was performed. Controls were screened for sleep disordered breathing (SDB) at the time of delivery using a questionnaire. Women at low risk for OSA were selected. Marker levels were adjusted for gestational age and race and reported as multiples of median and later adjusted for body mass index (BMI). Results: Twenty-four OSA cases and 166 controls were identified. Women with OSA had a higher mean BMI when compared to controls (37.1 +12.7 vs. 24.1 + 5.1, p=0.03). Estriol (uE3) MoM levels were lower in women with OSA compared to controls, even after adjusting for BMI, 0.74 (interquartile range (IQR) 0.45) vs. 1.06 (IQR 0.38), respectively, p=0.026. Once adjusted for BMI, alpha feto-protein (AFP) MoM levels were no longer significantly different in women with OSA compared to controls. Conclusion: OSA is associated with reduced serum uE3 levels, independently of BMI, possibly indicating fetal distress.
Objective
This study aimed to prospectively examine the impact of chronic vs pregnancy-onset habitual snoring on gestational hypertension, preeclampsia, and gestational diabetes.
Study Design
Third-trimester pregnant women were recruited from a large, tertiary medical center from March 2007 through December 2010 and screened for the presence and duration of habitual snoring, as a known marker for sleep-disordered breathing. Clinical diagnoses of gestational hypertension, preeclampsia, and gestational diabetes were obtained.
Results
Of 1719 pregnant women, 34% reported snoring, with 25% reporting pregnancy-onset snoring. After adjusting for confounders, pregnancy-onset, but not chronic, snoring was independently associated with gestational hypertension (odds ratio, 2.36; 95% confidence interval, 1.48–3.77; P < .001) and preeclampsia (odds ratio, 1.59; 95% confidence interval, 1.06–2.37; P = .024) but not gestational diabetes.
Conclusion
New-onset snoring during pregnancy is a strong risk factor for gestational hypertension and preeclampsia. In view of the significant morbidity and health care costs associated with hypertensive diseases of pregnancy, simple screening of pregnant women may have clinical utility.
Objective:
To investigate the associations between obstructive sleep apnea (OSA) and maternal and neonatal morbidities in a cohort of obese gravid women.
Methods:
Participants were enrolled in a prospective observational study designed to screen for OSA and describe the possible risk factors for and outcomes of OSA among obese (body mass index [BMI, calculated as weight (kg)/[height (m)]2] 30 or higher) pregnant women. Women underwent an overnight sleep study using a portable home monitor. Studies were manually scored by a central masked sleep reading center using American Academy of Sleep Medicine diagnostic criteria. An apnea hypopnea index of 5 or more was considered diagnostic of OSA. Perinatal outcomes were compared between women with and without OSA.
Results:
Among 175 women, OSA prevalence was 15.4% (13 mild, 9 moderate, 5 severe). Compared with no OSA (apnea hypopnea index less than 5), the OSA group had a higher BMI (46.8±12.2 compared with 38.1±7.5; P=.002) and more chronic hypertension (55.6% compared with 32.4%, P=.02). Maternal complications included maternal death (n=1, amniotic fluid embolus [no OSA group]) and cardiac arrest (n=1, intraoperative at cesarean delivery [OSA group]). One previable birth and two stillbirths occurred in the no OSA group. Among live births, OSA was associated with more frequent cesarean delivery (65.4% compared with 32.8%; P=.003), preeclampsia (42.3% compared with 16.9%; P=.005), and neonatal intensive care unit admission (46.1% compared with 17.8%; P=.002). After controlling for BMI, maternal age, and diabetes, OSA (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.1-11.3), previous preeclampsia (OR 2.79, 95% CI 1.09-7.19), and hypertension (OR 4.25, 95% CI 1.67-10.77) were associated with development of preeclampsia.
Conclusion:
Obstructive sleep apnea among obese pregnant women is associated with more frequent preeclampsia, neonatal intensive care unit admissions, and cesarean delivery.
Level of evidence:
II.
Objective: To determine if the influence of preeclampsia on birth size varies with clinical manifestations of the disease, and to evaluate whether maternal factors, such as smoking, modify the effect of preeclampsia on fetal growth.
Methods: Among 12,804 deliveries in a population of approximately 239,000 over a 3-year period, 307 live singleton infants were born after preeclamptic pregnancies. We compared those with a sample of 619 control infants. Preeclampsia was defined as increased diastolic blood pressure (BP) (increase of at least 25 mmHg to at least 90 mmHg) and proteinuria after 20 weeks' gestation. Clinical manifestations were classified according to BP and proteinuria into subgroups of mild, moderate, or severe (including cases with eclampsia and hemolysis, elevated liver enzymes, low platelets [HELLP] syndrome) preeclampsia, and according to gestational age at onset, as early or late preeclampsia. Birth size was expressed as the ratio between observed and expected birth weights, and infants smaller than two standard deviations from expected birth weights were classified as small for gestational age (SGA).
Results: Preeclampsia was associated with a 5% (95% confidence interval [CI] 3%, 6%) reduction in birth weight. In severe preeclampsia, the reduction was 12% (9%, 15%), and in early-onset disease, birth weight was 23% (18%, 29%) lower than expected. The risk of SGA was four times higher (relative risk [RR] = 4.2; 95% CI 2.2, 8.0) in infants born after preeclampsia than in control pregnancies. Among nulliparas, preeclampsia was associated with a nearly threefold higher risk of SGA (RR = 2.8; 1.2, 5.9), and among paras, the risk of SGA was particularly high after recurrent preeclampsia (RR = 12.3; 3.9, 39.2). In relation to preeclampsia and maternal smoking, the results indicated that each factor might contribute to reduced growth in an additive manner.
Conclusion: Severe and early-onset preeclampsia were associated with significant fetal growth restriction. The risk of having an SGA infant was dramatically higher in women with recurrent preeclampsia. Birth weight reduction related to maternal smoking appeared to be added to that caused by preeclampsia, suggesting that there is no synergy between smoking and preeclampsia on growth restriction.
Background:
Our goal was to determine the prevalence of metabolic syndrome in women following a pregnancy complicated by preeclampsia and to determine whether this changes between one- and three-years postpartum.
Methods:
We recruited women into a longitudinal prospective cohort following a pregnancy with or without preeclampsia. The prevalence of cardiometabolic factors were assessed at one- and three-years postpartum. A total of 217 women completed a visit at one year postpartum (n = 99 preeclampsia, n = 118 control subjects) and 120 completed a visit at three-years (n = 73 preeclampsia, n = 47 control subjects).
Results:
The prevalence of metabolic syndrome at one- and three-years postpartum was significantly greater in women who had preeclampsia (18.18% at one year, 21.92% at three-years) than in control subjects (6.78%, 6.38%) (P < 0.05), but did not change over time.
Conclusions:
Given the difficulty in following women long-term, either clinically or as part of study, and because cardiometabolic factors do not change significantly between one- and three-years postpartum, strategies for health preservation and disease prevention should be adopted in the first-year postpartum.
We examined the risk of adverse pregnancy outcomes, including low birthweight (LBW), preterm birth, small for gestational age (SGA), cesarean section (CS), low Apgar score (at 5 minutes after delivery), and preeclampsia in pregnant women with and without obstructive sleep apnea (OSA).
Our subjects included 791 women with OSA and 3955 randomly selected women without OSA. We performed conditional logistic regression analyses to examine the risks of adverse pregnancy outcomes between women with and without OSA.
Compared with women without OSA, adjusted odds ratios for LBW, preterm birth, SGA infants, CS, and preeclampsia in women with OSA were 1.76 (95% confidence interval [CI], 1.28-2.40), 2.31 (95% CI, 1.77-3.01), 1.34 (95% CI, 1.09-1.66), 1.74 (95% CI, 1.48-2.04), and 1.60 (95% CI, 2.16-11.26), respectively.
Pregnant women with OSA are at increased risk for having LBW, preterm, and SGA infants, CS, and preeclampsia, compared with pregnant women without OSA.
Symptoms of sleep-disordered breathing are more common in pregnant women compared with nonpregnant women. It is likely that physiology of pregnancy predisposes to the development or worsening of sleep-disordered breathing, but some physiologic changes may also be protective against the development of this disease. Clinical presentation may be less predictive of sleep disordered breathing in pregnancy than in the non-pregnant population; nonetheless, snoring is associated with adverse pregnancy outcomes. Treatment strategies are similar to the nonpregnant population, however, pregnancy-specific scenarios may arise and these subtleties are addressed in this review.
Both gestational diabetes mellitus (GDM) and gestational impaired glucose tolerance (GIGT) identify women at risk of future cardiovascular disease, although the mediators of this risk are unknown. Because lipid factors can contribute to cardiovascular risk, we sought to characterize the relationship between gestational glucose tolerance status and lipid profile in pregnancy and the postpartum.
Fasting lipids were measured in 482 women in pregnancy and at 3 months postpartum. Antepartum glucose challenge test (GCT) and oral glucose tolerance test (OGTT) defined four gestational glucose tolerance groups: GDM (n = 136), GIGT (n = 89), abnormal GCT with normal glucose tolerance (NGT) on OGTT (abnormal GCT NGT) (n = 170), and normal GCT with NGT on OGTT (normal GCT NGT) (n = 87).
In pregnancy, there were no significant differences between the groups in total and low-density lipoprotein (LDL) cholesterol, triglycerides, total cholesterol to high-density lipoprotein (HDL) cholesterol ratio, apolipoprotein B (apoB), apolipoprotein A1 (apoA1), and apoB to apoA1 ratio. At 3 months postpartum, however, each of the following lipid parameters progressively increased from normal GCT NGT to abnormal GCT NGT to GIGT to GDM: total cholesterol (P = 0.0047), LDL (P = 0.0002), triglycerides (P = 0.0002), total cholesterol to HDL ratio (P < 0.0001), apoB (P = 0.0003), and apoB to apoA1 ratio (P = 0.0014). Furthermore, on multiple linear regression analyses, GDM emerged as an independent predictor of postpartum total cholesterol (t = 3.09, P = 0.0021), LDL (t = 3.81, P = 0.0002), triglycerides (t = 3.38, P = 0.0008), total cholesterol to HDL ratio (t = 3.76,P = 0.0002), apoB (t = 4.12, P < 0.0001), and apoB to apoA1 ratio (t = 3.07, P = 0.0023). GIGT was an independent predictor of postpartum total cholesterol to HDL ratio (t = 2.27, P = 0.0239), apoB (t = 2.04, P = 0.0416), and apoB to apoA1 ratio (t = 1.97, P = 0.049).
Compared with their peers, women with GDM and GIGT have a more atherogenic lipid profile by 3 months postpartum, characterized by increased LDL and apoB.
Clinic-based observational studies in men have reported that obstructive sleep apnea is associated with an increased incidence of coronary heart disease. The objective of this study was to assess the relation of obstructive sleep apnea to incident coronary heart disease and heart failure in a general community sample of adult men and women.
A total of 1927 men and 2495 women > or =40 years of age and free of coronary heart disease and heart failure at the time of baseline polysomnography were followed up for a median of 8.7 years in this prospective longitudinal epidemiological study. After adjustment for multiple risk factors, obstructive sleep apnea was a significant predictor of incident coronary heart disease (myocardial infarction, revascularization procedure, or coronary heart disease death) only in men < or =70 years of age (adjusted hazard ratio 1.10 [95% confidence interval 1.00 to 1.21] per 10-unit increase in apnea-hypopnea index [AHI]) but not in older men or in women of any age. Among men 40 to 70 years old, those with AHI > or =30 were 68% more likely to develop coronary heart disease than those with AHI <5. Obstructive sleep apnea predicted incident heart failure in men but not in women (adjusted hazard ratio 1.13 [95% confidence interval 1.02 to 1.26] per 10-unit increase in AHI). Men with AHI > or =30 were 58% more likely to develop heart failure than those with AHI <5.
Obstructive sleep apnea is associated with an increased risk of incident heart failure in community-dwelling middle-aged and older men; its association with incident coronary heart disease in this sample is equivocal.
We sought to evaluate the impact of short sleep duration (SSD) and frequent snoring (FS) on glucose metabolism during pregnancy.
We conducted a prospective cohort study of healthy nulliparas who participated in a sleep survey study. SSD was defined as <7 hours of sleep per night and FS, as snoring >or=3 nights per week. Outcomes included 1-hour oral glucose tolerance results and the presence of gestational diabetes mellitus (GDM). Univariate and multivariate analyses were performed.
A total of 189 women participated; 48% reported an SSD and 18.5% reported FS. SSD and FS were associated with higher oral glucose tolerance values: SSD (116 +/- 31 vs 105 +/- 23; P = .008) and FS (118 +/- 34 vs 108 +/- 25; P = .04). Both SSD (10.2% vs 1.1%; P = .008) and FS (14.3% vs 3.3%; P = .009) were associated with a higher incidence of GDM. Even after controlling for potential confounders, SSD and FS remained associated with GDM.
SSD and FS are associated with glucose intolerance in pregnancy.
Women with gestational diabetes are at increased risk of developing type 2 diabetes, but the risk and time of onset have not been fully quantified. We therefore did a comprehensive systematic review and meta-analysis to assess the strength of association between these conditions and the effect of factors that might modify the risk.
We identified cohort studies in which women who had developed type 2 diabetes after gestational diabetes were followed up between Jan 1, 1960, and Jan 31, 2009, from Embase and Medline. 205 relevant reports were hand searched. We selected 20 studies that included 675 455 women and 10 859 type 2 diabetic events. We calculated and pooled unadjusted relative risks (RRs) with 95% CIs for each study using a random-effects model. Subgroups analysed were the number of cases of type 2 diabetes, ethnic origin, duration of follow-up, maternal age, body-mass index, and diagnostic criteria.
Women with gestational diabetes had an increased risk of developing type 2 diabetes compared with those who had a normoglycaemic pregnancy (RR 7.43, 95% CI 4.79-11.51). Although the largest study (659 164 women; 9502 cases of type 2 diabetes) had the largest RR (12.6, 95% CI 12.15-13.19), RRs were generally consistent among the subgroups assessed.
Increased awareness of the magnitude and timing of the risk of type 2 diabetes after gestational diabetes among patients and clinicians could provide an opportunity to test and use dietary, lifestyle, and pharmacological interventions that might prevent or delay the onset of type 2 diabetes in affected women.
None.
There has been considerable debate over whether asymptomatic neonatal hypoglycaemia results in neurological damage. In a detailed multicentre study of 661 preterm infants hypoglycaemia was found to be common. Moderate hypoglycaemia (plasma glucose concentration less than 2.6 mmol/l) occurred in 433 of the infants and in 104 was found on three to 30 separate days. There was considerable variation among the centres, implying differences in decisions to intervene. The number of days on which moderate hypoglycaemia occurred was strongly related to reduced mental and motor development scores at 18 months (corrected age), even after adjustment for a wide range of factors known to influence development. When hypoglycaemia was recorded on five or more separate days adjusted mental and motor developmental scores at 18 months (corrected age) were significantly reduced by 14 and 13 points respectively, and the incidence of neurodevelopmental impairment (cerebral palsy or developmental delay) was increased by a factor of 3.5 (95% confidence interval 1.3 to 9.4). These data suggest that, contrary to general belief, moderate hypoglycaemia may have serious neurodevelopmental consequences, and reappraisal of current management is urgently required.
Menopause is considered to be a risk factor for sleep-disordered breathing, but this hypothesis has not been adequately tested. The association of premenopause, perimenopause, and postmenopause with sleep-disordered breathing was investigated with a population-based sample of 589 women enrolled in the Wisconsin Sleep Cohort Study. Menopausal status was determined from menstrual history, gynecologic surgery, hormone replacement therapy, follicle-stimulating hormone, and vasomotor symptoms. Sleep-disordered breathing was indicated by the frequency of apnea and hypopnea events per hour of sleep, measured by in-laboratory polysomnography. Multivariable logistic regression was used to estimate odds ratios for having 5 or more and 15 or more apnea and hypopnea events per hour. Odds ratios (95% confidence interval), adjusted for age, body habitus, smoking, and other potential confounding factors, for 5 or more apnea and hypopnea events per hour were 1.2 (0.7, 2.2) with perimenopause and 2.6 (1.4, 4.8) with postmenopause; odds ratios for 15 or more apnea and hypopnea events per hour were 1.1 (0.5, 2.2) with perimenopause and 3.5 (1.4, 8.8) with postmenopause. The menopausal transition is significantly associated with an increased likelihood of having sleep-disordered breathing, independent of known confounding factors. Evaluation for sleep-disordered breathing should be a priority for menopausal women with complaints of snoring, daytime sleepiness, or unsatisfactory sleep.
A Working Group on Research in Hypertension in Pregnancy was recently convened by the National Heart, Lung, and Blood Institute to determine the state of knowledge in this area and suggest appropriate directions for research. Hypertensive disorders in pregnancy, especially preeclampsia, are a leading cause of maternal death worldwide and even in developed countries increase perinatal mortality rates 5-fold. Much has been learned about preeclampsia, but gaps in the knowledge necessary to direct therapeutic strategies remain. Oxidative stress is a biologically plausible contributor to the disorder that may be amenable to intervention. Hypertension that antedates pregnancy (chronic hypertension) bears many similarities to hypertension in nonpregnant women, but the special setting of pregnancy demands information to guide evidence-based therapy. The recommendations of the Working Group are to attempt a clinical trial of antioxidant therapy to prevent preeclampsia that is be complemented by mechanistic research to increase understanding of the genetics and pathogenesis of the disorder. For chronic hypertension, clinical trials are recommended to direct choice of drugs, evaluate degree of control, and assess implications to the mother and fetus. Recommendations to increase participation in this research are also presented.