Article

Obstructive sleep apnea in pregnancy is associated with adverse maternal outcomes: a national cohort

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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.

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... Additional meta-analyses were conducted using the Mantel-Haenszel method to compute OR with 95% CI of dichotomous data using events of pre-pregnant or pregnant overweight (BMI ≥ 25 kg m −2 ) and obesity (BMI ≥ 30 kg m −2 ) in high and low risk of sleep apnea as shown in Table 3. Seventeen studies (Antony et al., 2014;Bin et al., 2016;Bourjeily et al., 2017;Chen et al., 2012;Fernandez Alonso et al., 2015;Jaimchariyatam et al., 2019;Kalmbach et al., 2019;Ko et al., ,2012Ko et al., , , 2013Liu & Xue, 2018;Lockhart et al., 2015;Naghi et al., 2011;Olivarez et al., 2011;Pamidi et al., 2016;Rice et al., 2015;Tantrakul et al., 2015) were included using either objective or subjective tools to measure sleep apnea. In general, women with overweight and obese were at greater chance of ...
... A total of 80 fulltext were selected for eligibility based on their abstracts, and 34 articles were excluded for varied reasons outlined in the PRISMA flowchart (Figure 2). Finally, 46 articles(Antony et al., 2014;Bassan et al., 2016;Bin et al., 2016;Bourjeily et al., 2017;Chen et al., 2012Chen et al., , 2019Dominguez et al., 2018;Facco et al., 2010Facco et al., , 2017Facco, Ouyang, Zee, Strohl, et al., 2014;Fernandez Alonso et al., 2015;Fung et al., 2013;Higgins et al., 2011;Jaimchariyatam et al., 2019;Kalmbach et al., 2019;Ko et al., ,2012Ko et al., , , 2013Köken et al., 2007;Liu & Xue, 2018;Lockhart et al., 2015;Loube et al., 1996;Louis et al., 2012;Micheli et al., 2011;Miyagawa et al., 2011;Naghi et al., 2011;Na-Rungsri et al., 2016;Okun & O'Brien, 2018;Olivarez et al., 2011;Pamidi et al., 2016;Perez-Chada et al., 2007;Pien et al., 2005Pien et al., , 2014Rawal et al., 2017;Rice et al., 2015;Sahin et al., 2008;Sarberg et al., 2014;Shao et al., 2017;Tantrakul et al., 2015;Tauman et al., 2011Tauman et al., , 2012Tauman et al., , 2015Telerant et al., 2018;Ugur et al., 2012;Wang et al., 2017;Yang et al., 2016) met the inclusion criteria and were selected for our meta-analysis. ...
... Bourjeily et al., 2017) with a median of 248 among uncomplicated pregnancies (n = 30), complicated pregnancies (n = 7), and mixture of uncomplicated and complicated pregnancies (n = 9). ...
Article
Despite the well-established correlation of weight and sleeping problems, little is known about the nature of the association. The present study examined whether pregnant women with high body mass index have a risk of developing sleep problems, and identified any covariates that affect this relationship. We systematically searched electronic databases, specialized journals, various clinical trial registries, grey literature databases and the reference list of the identified studies. All observational studies were obtained from inception until 9 August 2020. The Newcastle– Ottawa Scale was adopted to assess the quality of studies. Stata software was used to conduct meta- analysis and meta-regression. Forty- six observational studies involv-ing 2,240,804 participants across 16 countries were included. Quality assessment scores ranged from 4 to 10 (median = 6). Meta- analyses revealed that the risk of sleep apnea, habitual snoring, short sleep duration and poor sleep quality is increased in pregnant women with high body mass index, but not for daytime sleepiness, insomnia or restless legs syndrome. Subgroup differences were detected on body mass index between different regions, nature of population, year of publication, age group and study quality. Random-effects meta- regression analyses showed that year and quality of publication were covariates on the relationships between pre- pregnant body mass index and sleep apnea risk. Our review shows that sleep apnea, habitual snoring, short sleep duration and poor sleep quality are important concerns for pregnant women with high body mass index. Developing screening and targeted interventions is recommended to promote efficacious perinatal care.
... However, the BMI effect on OSA or GDM has not been completely eliminated in these studies. Consequently, there is an association between GDM and OSA [19,40]. Obesity may be a confounding factor of the association between OSA and GDM. ...
... However, Bourjeily et al. confirmed that OSA was associated with GDM (aOR, 1.51; 95% CI, 1.34-1.72) after adjusting for potential confounding factors (maternal obesity, pre-pregnancy hypertension, pre-pregnancy diabetes, maternal age, race/ethnicity, multiple births, tobacco use, alcohol use, drug use, rural/urban status, coronary heart disease, anemia, hyperlipidemia, hypothyroidism, disorders of the adrenal gland) in a study in which 1,577,632 deliveries women were included [40]. Moreover, GDM was found to be associated with the OSA (aOR, 6.60; 95% CI, 1.15-37.96) ...
... [17]. Consequently, there is an association between GDM and OSA after adjusting for age, BMI, chronic hypertension, and pregnancy-related weight gain or not [19,30,40]. In conclusion, there is an association between OSA and GDM, which may not be caused by obesity. ...
Article
Full-text available
Obstructive sleep apnea (OSA) usually leads to the occurrence of diabetes. Gestational diabetes mellitus (GDM) is a common gestational complication associated with adverse maternal and fetal outcomes. Increasing studies suggest that women with OSA during pregnancy may be at a significantly greater risk of developing GDM. It is crucial to explore the association between OSA and GDM and the mechanisms underlying this association. In this review, we presented a comprehensive literature review of the following: the association between OSA and GDM, the possible mechanisms of this association, and the effects of continuous positive airway pressure (CPAP) on OSA with GDM. The results showed that most authors suggested that there was an association between OSA and GDM. The intermittent hypoxemia (IH) and reduction of slow-wave sleep (SWS) may be the key to this association. IH induces the products of oxidative stress and inflammation as well as dysregulation of the hypothalamic–pituitary–adrenal, which lead to diabetes. In addition, SWS reduction in OSA enhances the inflammation by increasing the inflammatory cytokines, increases the sympathetic activation, and causes changes in leptin level, which result in the development of GDM. Additionally, whether CPAP is beneficial to GDM remains still unclear.
... [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. ...
... Snoring, a mild form of SDB, increases from 7% of women in the first trimester of pregnancy to up to 48% in the week prior to birth [7]. Obstructive sleep apnea (OSA), a more serious form of SDB, increases from 4-6% of pregnant women in their first trimester to up to 9-20% of women in their third trimester [8,9] and is also associated with adverse maternal health outcomes [10]. ...
... While maternal SDB in pregnancy is known to be associated with multiple maternal obstetric complications, such as hypertensive disorders, diabetes, and abnormal fetal growth [9][10][11][12][13], there is limited knowledge about possible associations between SDB in pregnancy and maternal depression. Depression is a common health complication in pregnancy and is associated with adverse maternal, fetal, and child health outcomes [5,14]. ...
Article
Full-text available
Sleep disordered breathing (SDB) and depression are both common complications of pregnancy and increase risk for adverse maternal and neonatal outcomes. SDB precedes onset of depression in non-pregnant adults; however, the longitudinal relationship has not been studied in pregnancy. The present research examined temporal associations between SDB and depressive symptoms in 175 pregnant women at risk for SDB (based on frequent snoring and obesity), but without an apnea hypopnea index of ≥5 events per hour at enrollment. Women completed a self-report assessments of depressive symptoms using PHQ-9 and in-home level III sleep apnea monitoring at approximately 12- and 32-weeks’ gestation. We also assessed the risk for SDB using the Berlin Questionnaire in early pregnancy. Results revealed that measures of SDB in early pregnancy as assessed by in-home sleep study, but not by self-reported SDB, predicted elevated depressive symptoms in late pregnancy. SDB in late pregnancy was not associated with depressive symptoms. To conclude, these findings suggest that SDB may increase the risk for elevated depressive symptoms as pregnancy progresses.
... Obstructive sleep apnea-hypopnea may develop or worsen over the course of pregnancy, reaching an estimated prevalence of 17-45% of women in the third trimester (Pamidi and Kimoff, 2018). There is increasing evidence that maternal OSAH is associated with a greater risk of HDP (Champagne et al., 2009;Ding et al., 2014;Pamidi et al., 2014;Bourjeily et al., 2017;Li et al., 2018;Liu et al., 2019;Querejeta Roca et al., 2020;Lu et al., 2021) and other adverse pregnancy outcomes, including gestational diabetes mellitus and small for gestational age infants (SGA) (Pamidi et al., 2016). Recent meta-analyses have reported adjusted odds ratios of 1.93-2.38 for the association between OSAH and gestational hypertension (Ding et al., 2014;Pamidi et al., 2014;Li et al., 2018;Liu et al., 2019;Lu et al., 2021). ...
... Estimates of the prevalence of OSAH in pregnancy by the third trimester range from 17 to 45% (Pamidi and Kimoff, 2018). Several studies have shown that OSAH is strongly associated with a greater risk of HDP (Champagne et al., 2009;Ding et al., 2014;Pamidi et al., 2014;Bourjeily et al., 2017;Li et al., 2018;Liu et al., 2019;Querejeta Roca et al., 2020;Lu et al., 2021). In keeping with this, in the present study, out of 67 HDP women who initially met eligibility criteria, 56 (83.6%) tested positive for OSAH. ...
Article
Full-text available
Rationale: Maternal obstructive sleep apnea-hypopnea (OSAH) is associated with hypertensive disorders of pregnancy (HDP). Attenuation of the normal nocturnal blood pressure (BP) decline (non-dipping) is associated with adverse pregnancy outcomes. OSAH is associated with nocturnal non-dipping in the general population, but this has not been studied in pregnancy. We therefore analyzed baseline data from an ongoing RCT (NCT03309826) assessing the impact of OSAH treatment on HDP outcomes, to evaluate the relationship of OSAH to 24-h BP profile, in particular nocturnal BP dipping, and measures of arterial stiffness. Methods: Women with a singleton pregnancy and HDP underwent level II polysomnography. Patients with OSAH (apnea-hypopnea index (AHI) ≥ 5 events/h) then underwent 24-h ambulatory BP monitoring and arterial stiffness measurements (applanation tonometry, SphygmoCor). Positive dipping was defined as nocturnal systolic blood pressure (SBP) dip ≥ 10%. The relationships between measures of OSAH severity, measures of BP and arterial stiffness were evaluated using linear regression analyses. Results: We studied 51 HDP participants (36.5 ± 4.9 years, BMI 36.9 ± 8.6 kg/m ² ) with OSAH with mean AHI 27.7 ± 26.4 events/h at 25.0 ± 4.9 weeks’ gestation. We found no significant relationships between AHI or other OSA severity measures and mean 24-h BP values, although BP was generally well-controlled. Most women were SBP non-dippers (78.4%). AHI showed a significant inverse correlation with % SBP dipping following adjustment for age, BMI, parity, gestational age, and BP medications (β = −0.11, p = 0.02). Significant inverse correlations were also observed between AHI and DBP (β = −0.16, p = 0.01) and MAP (β = −0.13, p = 0.02) % dipping. Oxygen desaturation index and sleep time below SaO 2 90% were also inversely correlated with % dipping. Moreover, a significant positive correlation was observed between carotid-femoral pulse wave velocity (cfPWV) and REM AHI (β = 0.02, p = 0.04) in unadjusted but not adjusted analysis. Conclusion: Blood pressure non-dipping was observed in a majority of women with HDP and OSAH. There were significant inverse relationships between OSAH severity measures and nocturnal % dipping. Increased arterial stiffness was associated with increasing severity of OSAH during REM sleep in unadjusted although not adjusted analysis. These findings suggest that OSAH may represent a therapeutic target to improve BP profile and vascular risk in HDP.
... Data from our laboratory and other groups have shown that both snoring [8] and OSA in pregnancy [9][10][11] are associated with an increased risk for GDM after adjusting for potential confounders such as maternal age and body mass index (BMI). Moreover, SDB is common in pregnant women with GDM and impacts 17%-72% of women with the diagnosis [1,12]. ...
Article
Study Objectives To examine the association between maternal sleep disordered breathing (SDB) and glucose metabolism in early gestation. Methods Women with body mass index (BMI) ≥27 kg/m2 and singleton pregnancies underwent in-home sleep study (HSAT) and homeostatic model assessment (HOMA) in early pregnancy. Insulin resistance (HOMA-IR) and β-cell function (HOMA %B) were derived. Exclusion criteria included pregestational diabetes, use of continuous positive airway pressure and chronic steroid therapy. We performed linear regression analyses to evaluate the association between continuous measures of SDB (respiratory event index (REI), and oxygen desaturation index (ODI)) and glucose metabolism parameters (HOMA-IR and HOMA %B). Analyses were adjusted for a set of a priori selected variables which included gestational age, maternal age, BMI, ethnicity, race, and parity. Results One hundred and ninety-two pregnant women with median (interquartile range) BMI of 35.14 (8.30) kg/m2 underwent HSAT and HOMA assessment at 11.14 (3) and 15.35 (4.14) gestational weeks, respectively. REI and ODI, as continuous values, were associated with HOMA-IR after adjusting for covariates. OSA (obstructive sleep apnea) diagnosis (REI > 5 events per hour) was not associated with HOMA-IR after adjusting for BMI (p ≥ 0.05). None of the parameters were associated with HOMA %B (p > 0.07). Conclusions SDB and insulin resistance are associated in early pregnancy, with a dose response association between respiratory event index severity and insulin resistance. Further studies are needed to establish if pregnant women with overweight and obesity may benefit from early SDB screening to improve glucose metabolic outcome. Clinical trials: NCT02412696, Positive Airway Pressure, Sleep Apnea, and the Placenta (PAP-SAP) https://clinicaltrials.gov/ct2/show/NCT02412696?term=Bourjeily&draw=2&rank=2 and NCT02917876, Predictors of De-novo Development of Obstructive Sleep Apnea in Pregnancy (Predictors) https://clinicaltrials.gov/ct2/show/NCT02917876?term=Bourjeily&draw=2&rank=1
... SMM rates were highly dependent on the SMM definitions, study populations, and adjustment models. For example, some investigators built on the CDC definitions [52,[61][62][63][64]; others used broad definitions that included maternal intensive care unit admission [21,25,28,40,53,65,67,71,73]. A number of studies extended SMM case finding to 42 days postpartum or readmission with SMM. ...
Article
Full-text available
Background Current interest in using severe maternal morbidity (SMM) as a quality indicator for maternal healthcare will require the development of a standardized method for estimating hospital or regional SMM rates that includes adjustment and/or stratification for risk factors. Objective To perform a scoping review to identify methodological considerations and potential covariates for risk adjustment for delivery-associated SMM. Search methods Following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews, systematic searches were conducted with the entire PubMed and EMBASE electronic databases to identify publications using the key term “severe maternal morbidity.” Selection criteria Included studies required population-based cohort data and testing or adjustment of risk factors for SMM occurring during the delivery admission. Descriptive studies and those using surveillance-based data collection methods were excluded. Data collection and analysis Information was extracted into a pre-defined database. Study design and eligibility, overall quality and results, SMM definitions, and patient-, hospital-, and community-level risk factors and their definitions were assessed. Main results Eligibility criteria were met by 81 studies. Methodological approaches were heterogeneous and study results could not be combined quantitatively because of wide variability in data sources, study designs, eligibility criteria, definitions of SMM, and risk-factor selection and definitions. Of the 180 potential risk factors identified, 41 were categorized as pre-existing conditions (e.g., chronic hypertension), 22 as obstetrical conditions (e.g., multiple gestation), 22 as intrapartum conditions (e.g., delivery route), 15 as non-clinical variables (e.g., insurance type), 58 as hospital-level variables (e.g., delivery volume), and 22 as community-level variables (e.g., neighborhood poverty). Conclusions The development of a risk adjustment strategy that will allow for SMM comparisons across hospitals or regions will require harmonization regarding: a) the standardization of the SMM definition; b) the data sources and population used; and c) the selection and definition of risk factors of interest.
... [181]. Large prospective cohort and population-based studies also associate sleep disordered breathing with higher odds of GDM [184,185]. In a case-control study of 46 women with newly diagnosed GDM and 46 healthy control subjects, matched for age, gestational age, body mass index, race, and parity, women with OSA had a higher GDM risk (OR 4.71; 95% CI = 1.05-21.04) ...
Article
Full-text available
Sleep is vital to human bodily function. Growing evidence indicates that sleep deprivation, disruption, dysrhythmia, and disorders are associated with impaired reproductive function and poor clinical outcomes in women. These associations are largely mediated by molecular-genetic and hormonal pathways, which are crucial for the complex and time sensitive processes of hormone synthesis/secretion, folliculogenesis, ovulation, fertilization, implantation, and menstruation. Pathologic sleep patterns are closely linked to menstrual irregularity, polycystic ovarian syndrome, premature ovarian insufficiency, sub/infertility, and early pregnancy loss. Measures of success with assisted reproductive technology are also lower among women who engage in shift work, or experience sleep disruption or short sleep duration. Extremes of sleep duration, poor sleep quality, sleep disordered breathing, and shift work are also associated with several harmful conditions in pregnancy, including gestational diabetes and hypertensive disorders. While accumulating evidence implicates pathologic sleep patterns in impaired reproductive function and poor reproductive outcomes, additional research is needed to determine causality and propose therapeutic interventions.
... The incidence of SA during pregnancy is on the rise worldwide in line with the obesity epidemic and is estimated to occur in approximately 15% of normal and >60% of high-risk pregnancies by the third trimester [14][15][16][17]. It is largely appreciated that maternal SA during pregnancy is detrimental to the health of the pregnancy and the newborn [10,[18][19][20][21][22][23][24][25][26][27][28]. Absent, however, is an understanding of whether maternal SA has long-term detrimental consequences on her offspring or if maternal SA impacts offspring neural development. ...
Article
Full-text available
Mounting epidemiologic and scientific evidence indicates that many psychiatric disorders originate from a complex interplay between genetics and early life experiences, particularly in the womb. Despite decades of research, our understanding of the precise prenatal and perinatal experiences that increase susceptibility to neurodevelopmental disorders remains incomplete. Sleep apnea (SA) is increasingly common during pregnancy and is characterized by recurrent partial or complete cessations in breathing during sleep. SA causes pathological drops in blood oxygen levels (intermittent hypoxia, IH), often hundreds of times each night. Although SA is known to cause adverse pregnancy and neonatal outcomes, the long-term consequences of maternal SA during pregnancy on brain-based behavioral outcomes and associated neuronal functioning in the offspring remain unknown. We developed a rat model of maternal SA during pregnancy by exposing dams to IH, a hallmark feature of SA, during gestational days 10 to 21 and investigated the consequences on the offspring's forebrain synaptic structure, synaptic function, and behavioral phenotypes across multiples stages of development. Our findings represent a rare example of prenatal factors causing sexually dimorphic behavioral phenotypes associated with excessive (rather than reduced) synapse numbers and implicate hyperactivity of the mammalian target of rapamycin (mTOR) pathway in contributing to the behavioral aberrations. These findings have implications for neuropsychiatric disorders typified by superfluous synapse maintenance that are believed to result, at least in part, from largely unknown insults to the maternal environment.
... 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. ...
Preprint
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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.
... 3 Literature to date from large prospective cohorts and populationbased studies shows that SDB is associated with significantly higher odds of having a diagnosis of GDM. 5,6 On the other hand, the prevalence of SDB in cohorts of pregnant women with GDM has ranged from 16% to 70%. 1,7 The underlying pathophysiology of the association remains unclear; however, several pathways and shared mechanisms have been proposed. ...
... For example, a study found that 40% of obese women had OSA when evaluated in the third trimester, compared to only 14% of those who were normal weight (Pien et al., 2014). OSA in pregnancy has been linked to adverse pregnancy outcomes including increased risk of gestational hypertension, pre-eclampsia, gestational DM (GDM), caesarean section, small for gestational age infants, postoperative wound infection, longer hospital stays, and rare medical and surgical complications (Bourjeily et al., 2017;Liu et al., 2018;Luque-Fernandez et al., 2013;Pamidi et al., 2016;Wanitcharoenkul et al., 2017). ...
Article
Obstructive sleep apnoea (OSA) is prevalent in obese women with gestational diabetes mellitus (GDM). The present pilot study explored associations between OSA severity and metabolites in women with GDM. A total of 81 obese women with diet‐controlled GDM had OSA assessment (median gestational age [GA] 29 weeks). The metabolic profile was assayed from fasting serum samples via liquid chromatography–mass spectrometry (LC‐MS) using an untargeted approach. Metabolites were extracted and subjected to an Agilent 1,290 UPLC coupled to an Agilent 6,545 quadrupole time‐of‐flight (Q‐TOF) MS. Data were acquired using electrospray ionisation in positive and negative ion modes. The raw LC‐MS data were processed using the OpenMS toolkit to detect and quantify features, and these features were annotated using the Human Metabolite Database. The feature data were compared with OSA status, apnea–hypopnea index (AHI), body mass index (BMI) and GA using “limma” in R. Correlation analyses of the continuous covariates were performed using Kendall’s Tau test. The p values were adjusted for multiple testing using the Benjamini–Hochberg false discovery rate correction. A total of 42 women (51.8%) had OSA, with a median AHI of 9.1 events/hr. There were no significant differences in metabolomics profiles between those with and without OSA. However, differential analyses modelling in GA and BMI found 12 features that significantly associated with the AHI. These features could be annotated to oestradiols, lysophospholipids, and fatty acids, with higher levels related to higher AHI. Metabolites including oestradiols and phospholipids may be involved in pathogenesis of OSA in pregnant women with GDM. A targeted approach may help elucidate our understanding of their role in OSA in this population.
... 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]. ...
Article
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.
... 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. ...
Article
Full-text available
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.
... 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. ...
Article
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.
... It has been seen that pregnant women are prone to develop SDB due to anatomical, physiological and hormonal changes. Snoring, which is considered as a hallmark of SDB, is much more common in the pregnant population and has been observed in 14-46% of pregnant women [12,13]. In studies conducted on Indian population, snoring and SDB were found in 18-27.5 and 7-9.5% of pregnant women, respectively [14,15]. ...
... Obesity is also an independent risk for poor maternal pregnancy outcomes (57), including operative delivery, postpartum hemorrhage, and wound infection (58,59). Obesity is commonly associated with other comorbidities including hypertension, hyperlipidemia, and obstructive sleep apnea (OSA) (60)(61)(62). OSA worsens insulin resistance and glycemia among pregnant women with obesity and can contribute to poor pregnancy outcomes (63). Therefore, women with diabetes who are obese should be screened for OSA prior to pregnancy if possible, and, if diagnosed, treated with continuous positive airway pressure. ...
Article
Full-text available
Context This review presents an up-to-date summary on management of Type 1 diabetes mellitus (T1DM) among women of reproductive age and covers the following time periods: preconception, gestation, and postpartum. Evidence acquisition A systematic search and review of the literature for randomized controlled trials and other studies evaluating management of T1DM before pregnancy, during pregnancy, and postpartum was performed. Evidence synthesis Preconception planning should begin early in the reproductive years for young women with T1DM. Preconception and during pregnancy, it is recommended to have near-normal glucose values to prevent adverse maternal and neonatal outcomes, including fetal demise, congenital anomaly, preeclampsia, macrosomia, neonatal respiratory distress, neonatal hyperbilirubinemia, and neonatal hypoglycemia. Conclusion Women with T1DM can have healthy, safe pregnancies with preconception planning, optimal glycemic control, and multidisciplinary care.
Article
Introduction. Obstructive sleep apnea (OSA) increases the risk of type 2 diabetes, and hyperinsulinemia. Pregnancy increases the risk of OSA; however, the relationship between OSA and gestational diabetes mellitus (GDM) is unclear. We aimed (1) to evaluate OSA prevalence in GDM patients; (2) to assess the association between OSA and GDM; and (3) to determine the relationships between sleep parameters with insulin resistance (IR). Methods. A total of 177 consecutive women (89 with GDM, 88 controls) in the third trimester of pregnancy underwent a hospital polysomnography. OSA was defined when the apnea-hypopnea index (AHI) was ≥5 h⁻¹. Results. Patients with GDM had higher pregestational body mass index (BMI) and neck circumference than controls, but no differences in snoring or OSA-symptoms, or AHI (3.2±6.0 vs. 1.9±2.7 h⁻¹, p=.069). OSA prevalence was not significantly different in both groups. We did not identify OSA as a GDM risk factor in the crude analysis 1.65 (95% CI:0.73-3.77; p=.232). Multiple regression showed that total sleep time (TST), TST spent with oxygen saturation< 90% (T90), and maximum duration of respiratory events as independent factors related with homeostasis model assessment of IR, while T90 was the only independent determinant of quantitative insulin sensitivity check index. Conclusion. OSA prevalence during the third trimester of pregnancy was not significantly different in patients with GDM than without GDM, and no associations between OSA and GDM determinants were found. We identified T90 and obstructive respiratory events length positive-related to IR, while TST showed an inverse relationship with IR in pregnant women.
Article
None: Obstructive sleep apnea (OSA) is a common disorder characterized by multiple episodes of airflow limitations and intermittent hypoxia. Pregnancy is a risk factor for developing OSA and OSA is associated with multiple adverse pregnancy outcomes and maternal morbidities, even beyond the gestational period. Despite the high prevalence of OSA and its impact on perinatal outcomes, there are no standard methods and optimal timing to screen for this disorder. Consequently, OSA is currently underdiagnosed in pregnancy. We present a case of severe OSA in pregnancy that developed in the third trimester of pregnancy after a negative study in early pregnancy. Our report emphasizes how lack of standardized screening and diagnostic methods in pregnancy can misdiagnose OSA, even in severe cases, and highlights the need for further research in this area.
Article
Study objectives: Habitual snoring has been associated with hypertensive disorders of pregnancy. However, exactly when blood pressure (BP) trajectories diverge between pregnant women with and without habitual snoring is unknown. Moreover, the potentially differential impact of chronic vs pregnancy-onset habitual snoring on maternal BP trajectories during pregnancy has not been examined. This study compared patterns of BP across pregnancy in 3 groups of women: those with chronic habitual snoring, those with pregnancy-onset habitual snoring, and nonhabitual snoring "controls." Methods: In a cohort study of 1,305 pregnant women from a large medical center, participants were asked about habitual snoring (≥ 3 nights/week) and whether their symptoms began prior to or during pregnancy. Demographic, health, and BP data throughout pregnancy were abstracted from medical charts. Linear mixed models were used to examine associations between habitual snoring-onset and pregnancy BP trajectories. Results: A third of women reported snoring prior to pregnancy (chronic snoring) and an additional 23% reported pregnancy-onset snoring. Mean maternal age (SD) was 29.5 (5.6), 30 (6), and 30.5 (5.7) years in controls, chronic, and pregnancy-onset snoring, respectively. Overall, women with pregnancy-onset snoring had higher mean systolic BP and diastolic BP compared to those with chronic habitual snoring or nonhabitual snoring. In gestational week-specific comparisons with controls, systolic BP became significantly higher around 18 weeks' gestation among women with pregnancy-onset snoring and in the third trimester among women with chronic snoring. These differences became detectable at 1 mm Hg and increased thereafter, reaching 3 mm Hg-BP difference at 40 weeks' gestation in women with pregnancy-onset snoring relative to controls. Pairwise mean differences in diastolic BP were significant only among women with pregnancy-onset snoring relative to controls, after 15 weeks' gestation. Conclusions: Pregnancy-onset and chronic maternal snoring are associated with higher BPs beginning in the second and third trimester, respectively. Pregnancy BP trajectories could identify critical windows for enhanced BP surveillance; the divergent BP trajectories suggest that the 2 groups of women with habitual snoring in pregnancy may need to be considered separately when gestational time intervals are evaluated for increased BP monitoring. Citation: Dunietz GL, Hao W, Shedden K, et al. Maternal habitual snoring and blood pressure trajectories in pregnancy. J Clin Sleep Med. 2022;18(1):31-38.
Article
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.
Article
Sleep disturbances are highly prevalent in pregnancy and are frequently overlooked as a potential cause of significant morbidity. The association between sleep disturbances and pregnancy outcomes remains largely controversial and needs to be clarified to guide management. To evaluate the association between sleep disturbances and maternal complications and adverse fetal outcomes we performed a systematic search of PubMed, Embase and Web of Science for English-language articles published from inception to March 6, 2020, including; observational studies of pregnant women with and without sleep disturbances assessing the risk of obstetric complications in the antenatal, intrapartum or postnatal period, and neonatal complications. Data extraction was completed independently by two reviewers. We utilized the Newcastle-Ottawa Scales to assess the methodological quality of included studies and random-effect models to pool the associations. A total of 120 studies with 58,123,250 pregnant women was included. Sleep disturbances were assessed, including poor sleep quality, extreme sleep duration, insomnia symptoms, restless legs syndrome, subjective sleep-disordered breathing and diagnosed obstructive sleep apnea. Significant associations were found between sleep disturbances in pregnancy and a variety of maternal complications and adverse fetal outcomes. Overall sleep disturbances were significantly associated with pre-eclampsia (odds ratio=2.80, 95% confidence interval: 2.38-3.30), gestational hypertension (1.74, 1.54-1.97), gestational diabetes mellitus (1.59, 1.45-1.76), cesarean section (1.47, 1.31-1.64), preterm birth (1.38, 1.26-1.51), large for gestational age (1.40, 1.11-1.77), and stillbirth (1.25, 1.08-1.45), but not small for gestational age (1.03, 0.92-1.16), or low birth weight (1.27, 0.98-1.64). Sleep disturbances were related to higher morbidities in pregnant women who are 30 years or older and overweight before pregnancy. The findings indicate that sleep disturbances, which are easily ignored and treatable for both pregnant women and clinical services, deserve more attention from health-care providers during prenatal counseling and health care services.
Article
Full-text available
Objective: Maternal sleep disordered breathing and sleep disruption have adverse effects on pregnancy outcomes through multiple potential pathophysiological pathways. We hypothesize that disordered maternal sleep also adversely impacts the neuromaturation of the fetus. Methods: Participants in this prospective observational study included 102 obese pregnant women (pre-pregnancy body mass index (BMI) > 30 kg/m2 ) at 36 weeks gestation. Fetal neuromaturation, defined through measures of fetal heart rate variability, motor activity, and motor-cardiac coupling, was quantified through digitized fetal actocardiography during an afternoon recording. Maternal sleep measures were collected overnight through polysomnography. Data analysis focused on multiple regression, controlling for maternal BMI, blood pressure, and diabetes. Results: Indicators of higher sleep disordered breathing were associated with delayed fetal neuromaturation and greater fetal motor activity. Less maternal sleep disruption (shorter REM latency, more REM sleep, and/or fewer transitions) was associated with higher fetal heart rate variability and coupling-based neuromaturation. Conclusion: Characteristics of disordered maternal sleep affect the developing fetal nervous system. It is unknown whether these results extend to populations that are not characterized by obesity. The influence of maternal sleep on the developing fetal nervous system has been understudied and may yield effects that persist beyond pregnancy.
Article
Study objectives: Obstructive sleep apnea (OSA) is common in pregnant women and is a risk factor for poor perinatal outcomes. The Berlin Questionnaire (BQ) is a validated OSA screening tool that is often used in pregnancy. However, its poor performance in this population is likely attributed to the scoring paradigm that primarily identifies obesity. Moreover, the associations between the BQ and pregnancy outcomes are often those same outcomes that are obesity-related. Therefore, this study examined associations between each of the three BQ domains, independently and jointly, in relation to gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP). Methods: Pregnant third-trimester women were recruited from a tertiary medical center and completed the BQ, which includes three independent domains: snoring; sleepiness; and obesity/high blood pressure. Medical records were accessed for diagnoses of GDM and HDP. Results: Of the 1,588 pregnant women, 44% had a positive BQ score. Women with a positive score for domains of snoring exclusively, sleepiness exclusively, or their combination did not have an increased risk for GDM or HDP. However, women without snoring or sleepiness, but with a positive score on the BMI/BP domain had increased odds of GDM (OR 2.0, 95%CI 1.3-3.3) and HDP (OR 2.9, 95%CI 1.6-5.5). Further, any positive score in domain combinations that included BMI/BP had increased odds of GDM and HDP compared with negative scores in all domains. In addition, presence of obesity without hypertension, snoring, or sleepiness, the odds of GDM and HDP were similarly increased. Conclusions: The poor performance of the BQ in screening for OSA risk, may be attributed to its predominant reliance on identification of obesity.
Article
Background Sleep-disordered breathing (SDB) in pregnancy is associated with adverse maternal outcomes. The relationship between SDB and infant birthweight is unclear. This study's primary aim is to determine if objectively measured SDB in pregnancy is associated with infant birthweight. Methods We measured SDB objectively in early (6-15 weeks’ gestation) and mid (22-31 weeks’ gestation) pregnancy in a large cohort of nulliparous women. SDB was defined as an Apnea-Hypopnea Index ≥5 and in secondary analyses we also examined measures of nocturnal hypoxemia. We used a modified Poisson regression approach to estimate relative risks (RR) of large-for-gestational-age (LGA: >90th percentile for gestational age) and small-for-gestational-age (SGA: <10th percentile for gestational age) birthweights. Results The prevalence of early-pregnancy SDB was nearly 4%. The incidence of mid-pregnancy SDB was nearly 6.0%. The prevalence of LGA and SGA was 7.4% and 11.9%, respectively. Early-pregnancy SDB was associated with a higher risk of LGA in unadjusted models (RR 2.2, 95% CI 1.3-3.5) but not BMI-adjusted models (aRR 1.0, 95% CI 0.6-1.8). Mid-pregnancy SDB was not associated with SGA or LGA. Mid-pregnancy nocturnal hypoxemia (% of sleep time <90% oxygen saturation) and increasing nocturnal hypoxemia from early to mid-pregnancy were associated with a higher risk of LGA in BMI-adjusted models. SDB and nocturnal hypoxemia were not associated with SGA. Conclusions SDB in pregnancy was not associated with an increased risk of LGA or SGA birthweight, independent of BMI. Some measures nocturnal hypoxemia were associated with an increase in LGA risk, independent of BMI. ClinicalTrials.gov Registration number NCT02231398.
Article
Type 2 diabetes mellitus (DM) is a growing problem among reproductive-aged women. Contemporary trends in obesity and delayed child-bearing are expected to result in an increasing number of pregnancies affected by type 2 DM. Women with known type 2 DM can greatly benefit from preconception care as improved periconception glycemic control and weight loss can decrease the neonatal and maternal risks associated with type 2 DM and pregnancy. Antenatal mainstays of management include frequent blood glucose monitoring, insulin therapy, optimization of coexisting medical conditions, and fetal surveillance. Careful attention to postpartum glucose control, infant feeding choices, and contraceptive counseling are important aspects of immediate postpartum care.
Chapter
Obstructive sleep apnea (OSA), while commonly diagnosed in obese men and women, is often underdiagnosed in pregnant women. Snoring, witnessed apneas, excessive daytime sleepiness, and fatigue are common symptoms of OSA. These symptoms overlap with normal physiologic changes in pregnancy. Many women experience reduced quality of sleep, reduced sleep efficiency, increasing arousals due to acid reflux, fetal movements, nocturia, and pressure on the urinary bladder as the pregnancy progresses. Complications of untreated OSA in pregnancy include gestational diabetes, gestational hypertension, pre-eclampsia, intrauterine growth retardation, and increased rates of cesarean sections (Bourjeily et al, Sleep Med 38:50–57, 2017). Treatment of OSA with continuous positive airway pressure (CPAP) is recommended for pregnant women with moderate to severe OSA, and conservative management may be considered for women with mild disease.
Chapter
Snoring occurs in about one-third of women by third trimester of pregnancy and prevalence of obstructive sleep apnea (OSA) in pregnancy is estimated between 10% and 20%. The prevalence of sleep apnea among pregnant women in the USA may be increasing, paralleling higher rates of obesity and older maternal age. Changes in respiratory physiology, anatomy, and endocrine physiology have both predisposing and protective effects on sleep-disordered breathing in pregnancy. Diagnosing OSA in pregnancy can be challenging; respiratory physiology is different during pregnancy, and home sleep testing can underestimate sleep apnea due to sleep disturbances that frequently occur in pregnant women. Furthermore, common sleep apnea screening questionnaires are not valid in perinatal women. Sleep apnea in pregnancy poses a risk of developing gestational hypertensive disorders and gestational diabetes, as well as more severe outcomes including cardiomyopathy, congestive heart failure, need for postpartum hysterectomy, and even death. Infants of women with sleep apnea have a higher risk of low birthweight, preterm delivery, and small for gestational age. Positive airway pressure therapy (e.g., CPAP) is the gold standard treatment for OSA in pregnancy, though more research is needed to improve access to and compliance with CPAP in the perinatal period and to determine whether CPAP mitigates the risks of sleep apnea in expectant and new mothers and their offspring.
Chapter
Obstructive sleep apnea (OSA) adversely impacts virtually all organ systems. Neurocognitive consequences include impairments in daytime alertness, attention/vigilance, long-term visual and verbal memory, visuospatial/constructional abilities, and executive function while neuropsychological ones include depression, somatic syndromes, anxiety, and attention deficit/hyperactivity disorder. Cardiovascular consequences of OSA include CHF, systemic hypertension, ischemic heart disease, atrial fibrillation, ventricular arrhythmia, and stroke. Respiratory consequences include poor symptom control in asthma, worse pulmonary function in chronic obstructive pulmonary disease (COPD), increased frequency of exacerbation in both asthma and COPD, increased prevalence and recurrence of pulmonary embolism, and a higher prevalence pulmonary hypertension. Endocrine consequences include diabetes mellitus, metabolic syndrome, and sexual dysfunction in men and women. Gastrointestinal consequences include gastroesophageal reflux disease and nonalcoholic fatty liver disease. Obstetric consequences include pregnancy-related hypertensive disorders and gestational diabetes, as well as maternal cardiovascular, pulmonary, and surgical complications. Perinatal consequences include low birth weight, preterm birth, NICU admission, and hyperbilirubinemia. Perioperative consequences include postoperative ICU transfer, respiratory complications, cardiovascular events, and neurologic complications. Accident-related consequences include motor vehicle crashes and work-related injuries. Oncologic consequences include increased cancer incidence including breast and colorectal cancer. Mortality-related consequences include higher death rates overall and from cardiovascular, noncardiovascular, and COPD-related causes. Nocturnal respiratory dysfunction (i.e., hypoxemia-reoxygenation and hypercapnia), poor sleep quality (i.e., increased arousals, poor sleep efficiency, and altered sleep architecture), and intrathoracic pressure variations result in oxidative stress, inflammation, sympathetic activation, endothelial dysfunction, neurohormonal changes, thrombophilia, and hemodynamic changes, which are the mechanisms for these adverse clinical outcomes.
Chapter
Sleep in pregnant and postpartum women commonly is disrupted as a result of multiple factors that vary across time. Sleep in early pregnancy often is disrupted by significant hormonal changes in women. As the pregnancy progresses, sleep can be challenged by physical changes and the potential onset of issues such as sleep-disordered breathing, restless legs and/or leg cramps, acid reflux, and physical discomfort and/or pain. In the postpartum period, sleep is affected most by infant care needs and resulting fragmentation of sleep. While sleep complaints are frequent in pregnant and postpartum women, objective studies of sleep in this population are actually relatively few. Recent research now is beginning to elucidate risk factors that potentially may be associated with poor sleep in pregnant and postpartum women, factors that may impact the physical (e.g., inflammation) and mental (e.g., stress, depression) health of mothers as well as their children (e.g., low-birth-weight). When examining the relationship between sleep and mood, subjective experience of sleep disturbance tends to predict mood disturbance better than objective measures of sleep problems. Obtaining sleep of sufficient quality and quantity is clearly an important concern for pregnant and postpartum women and therefore needs to remain an active area of interest for both researchers and clinicians.
Article
Sleep throughout a woman's life impacts her quality of life and medical comorbidities. The prevalence of sleep symptoms and disorders varies throughout a woman's life in association with the reproductive milestones of pregnancy and menopause. Studies have failed to identify a clear sex predominance of sleep disorders in childhood and adolescence. Sleep disturbances in pregnancy are common and may be associated with increased risk for adverse maternal outcomes. Menopause is associated with sleep disruption owing to increased rates of sleep-disordered breathing, development of insomnia owing to vasomotor symptoms and hormonal changes, circadian derangements, and changes in sleep architecture.
Article
The terms sex and gender are often used interchangeably, but have specific meaning when it comes to their effects on lung disease. There is now ample evidence that sex and gender affect the incidence, susceptibility, presentation, diagnosis, and severity of many lung diseases. Some conditions are more prevalent in women, such as asthma. Other conditions are seen almost exclusively in women, like lymphangioleiomyomatosis. Some life stages -such as pregnancy- are unique to women 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 COPD and greater cardiovascular morbidity in women with sleep disordered breathing. 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 women. This article is a state-of-the-art review of specific effects of sex and gender focused on epidemiology, disease presentation, risk factors and management of lung diseases. Pathobiologic mechanisms explaining sex differences in these diseases are beyond the scope of this manuscript. We review the recent literature and focus on recent guidelines about using sex and gender in research. We also review sex and gender differences in lung diseases.
Article
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
Article
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.
Article
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.
Article
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.
Chapter
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
Article
Sleep is vital to life, even when women enter into pregnancy state. Good sleep is important for a healthy pregnancy. Sleep disturbances are common during pregnancy and can be due to the change of pregnancy itself or the results of sleep disorders. There is growing evidence linking sleep disturbances with adverse maternal and fetal outcomes. Differentiation of sleep disorders in order to provide appropriate treatment as well as promoting good sleep for pregnant women is important. A multidisciplinary team to provide sleep care during antenatal period may be needed.
Article
Maternal mortality is increasing in the United States; many maternal deaths are linked to substandard care and withholding diagnostic tests or therapeutic options for fear of harm. Respiratory conditions are common in this population; however, caring for pregnant women with respiratory disease is complicated by physiologic changes. Safety of diagnostic tests as well as therapeutic interventions, changes in pharmacodynamics, and potential teratogenicity complicate the care of this population further. Appropriate care of pregnant women with respiratory conditions requires a good understanding of these nuances in the management, to provide appropriate care and improve the health and well-being of pregnant women.
Article
Full-text available
Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea (OSA), but its outcomes for the pregnant are still undefined. This study aims to review current CPAP intervention during pregnancy, discuss published trials, and propose relevant issues that have yet to be addressed satisfactorily about the cardiovascular, metabolic, fetal, and neonatal effects of CPAP treatment during gestation. Two authors independently conducted a systematic review until March 28th, 2021 on PubMed, BVS, and Cochrane Library, using PRISMA guidelines, and risk of bias. Discrepancies were reconciled by a third reviewer. Of 59 identified citations, eight original trials have submitted a total of 90 pregnant women to polysomnography and CPAP therapy. Four studies performed in samples with hypertension or preeclampsia presented blood pressure decrease or maintained the antihypertensive drug dose in the CPAP group. After CPAP utilization, one trial registered cardiac output and stroke volume increase with heart rate and peripheral vascular resistance decrease, which were correlated with birth weight increment. Others documented a higher Apgar in the CPAP group and more fetal movements during CPAP use. There was a reduction in serum uric acid and tumor necrosis factor-alpha in the CPAP groups whose blood pressure decreased. However, two weeks of CPAP use in women with gestational diabetes and OSA did not improve glucose levels but raised the insulin secretion in those adherents to CPAP. Despite these positive results without adverse effects, randomized controlled trials with standardized follow-up in larger populations are required to determine CPAP therapy recommendations in pregnancy.
Article
Sleep-disordered breathing (SDB) occurs in about 30% of pregnancies. The subject has been and is still neglected by both sleep specialists and especially in the clinical routine of gynecologists. However, the coincidence SDB and pregnancy represents an enormous risk for both the mother and unborn child. With regard to adverse pregnancy outcomes, pregnant women have an increased risk for gestational hypertension and diabetes, preeclampsia, and eclampsia. The rate of caesarian sections is increased. Furthermore, pregnant women with SDB have an increased mortality rate. With regard to the unborn and newborn child, the rate of miscarriages, premature births, and stillbirths is increased. Additionally, intrauterine growth retardation and postpartum disturbed development up to six years is reported. Continuous positive airway pressure (CPAP) is the gold standard of therapy even in pregnancy. CPAP therapy is able to prevent the above mentioned complications without disturbing the course of pregnancy. For both sleep specialists and gynecologists there is a need for raising the awareness of SDB disorders in pregnant women.
Article
Postpartum respiratory depression is a complex, multifactorial issue that encompasses a patient's baseline preexisting conditions, certain pregnancy-specific conditions or complications, as well as the iatrogenic element of various medications given in the peripartum period. In this review, we discuss many of these factors including obesity, sleep-disordered breathing, chronic lung disease, neuromuscular disorders, opioids, preeclampsia, peripartum cardiomyopathy, postpartum hemorrhage, amniotic fluid embolism, sepsis, acute respiratory distress syndrome (ARDS), and medications such as analgesics, sedatives, anesthetics, and magnesium. Current recommendations for screening, treatment, and prevention are also discussed.
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Synopsis Since the early understandings of obstructive sleep apnea (OSA), it has been clear that there are sex-dependent features of the disease. This article reviews our understanding of the sex differences in the epidemiology, pathophysiology, symptom presentation, morbidity/mortality, polysomnogram features, and treatment of OSA. Key concepts include: 2:1 male female prevalence ratio for OSA in the general population; increase in OSA prevalence in women across the menopausal spectrum; greater upper airway collapsibility in men despite inherently larger airways; greater array of sleep-related symptoms in women with OSA which may hinder recognition of the disease; significant impact of OSA on functional status and health-related quality of life in women; milder polysomnographic presentation of OSA in women; and uncertainties on whether there are differential gender susceptibilities to cardiovascular and metabolic complications of OSA or treatment responses. OSA in pregnancy and impact of gender in central sleep apnea syndromes are also explored.
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Objectives Obstructive sleep apnea (OSA) is linked to many health comorbidities. We aimed to ascertain if OSA correlates with a rise in poor obstetrical outcomes. Methods Employing the United States’ Healthcare Cost and Utilization Project – National Inpatient Sample, we performed our retrospective cohort study including all women who delivered between 2006 and 2015. ICD-9 codes were used to characterize women as having a diagnosis of OSA. Temporal trends in pregnancies with OSA were studied, baseline features were evaluated among gravidities in the presence and absence of OSA, and multivariate logistic regression analysis was utilized in assessing consequences of OSA on patient and newborn outcomes. Results Of a total 7,907,139 deliveries, 3,115 belonged to patients suffering from OSA, resulting in a prevalence of 39 per 100,000 deliveries. Rates rose from 10.14 to 78.12 per 100,000 deliveries during the study interval (p<0.0001). Patients diagnosed with OSA were at higher risk of having pregnancies with preeclampsia, OR 2.2 (95% CI 2.0–2.4), eclampsia, 4.1 (2.4–7.0), chorioamnionitis, 1.4 (1.2–1.8), postpartum hemorrhage, 1.4 (1.2–1.7), venous thromboembolisms, 2.7 (2.1–3.4), and to deliver by caesarean section, 2.1 (1.9–2.3). Cardiovascular and respiratory complications were also more common among these women, as was maternal death, 4.2 (2.2–8.0). Newborns of OSA patients were at elevated risk of being premature, 1.3 (1.2–1.5) and having congenital abnormalities, 2.3 (1.7–3.0). Conclusions Pregnancies with OSA were linked to an elevated risk of poor maternal and neonatal outcomes. During pregnancy, OSA patients should receive attentive follow-up care in a tertiary hospital.
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Background Obstructive sleep apnea affects approximately 11% of women of reproductive age, although it is often undetected and untreated. Previous studies suggest an association between obstructive sleep apnea and adverse maternal outcomes. Herein, we aim to better characterize the relationship between obstructive sleep apnea and maternal outcomes. Methods Using the State Inpatient Databases, we performed a retrospective analysis of parturients ≥18 years old having inpatient deliveries in Florida, New York, California, Maryland, and Kentucky from 2007 to 2014. Outcomes included maternal pre-existing conditions, in-hospital mortality, maternal-fetal conditions and complications, and hospital length of stay >5 days. Results Our cohort consisted of 6 911 916 parturients of whom 4326 (0.06%) had obstructive sleep apnea. Women with obstructive sleep apnea were more likely to present with pre-existing conditions, such as obesity and pre-pregnancy diabetes. After adjusting for patient- and hospital-level confounders in our multivariate analysis, obstructive sleep apnea status was associated with an increased odds of maternal-fetal conditions and complications, including pre-eclampsia (aOR 2.05, 95% CI 1.87 to 2.26), pulmonary edema (aOR 4.73, 95% CI 2.84 to 7.89), cesarean delivery (aOR 1.96, 95% CI 1.81 to 2.11), early onset delivery (aOR 1.28, 95% CI 1.17 to 1.40), and length of stay >5 days (aOR 2.42, 95% CI 2.21 to 2.65). Obstructive sleep apnea was not significantly associated with a higher risk of in-hospital mortality. Conclusions Pregnant women with obstructive sleep apnea have a significantly higher adjusted risk of adverse maternal outcomes compared with women without obstructive sleep apnea.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
Article
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.
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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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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