Obstructive Sleep Apnea during Pregnancy: What Providers Need to Know

June 2, 2022
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Pregnant women need a lot of rest, but they aren’t always able to get the sleep they need. Women often accept poor-quality sleep as a consequence of the physical, hormonal, and psychological changes of pregnancy.10 Back pain, insomnia, and getting up multiple times in the night to use the bathroom can put a real damper on sleep.

However, your pregnant patients should not dismiss their sleepless nights as something to suffer through. They could be suffering from a sleep issue common among pregnant women, which can have a much more serious impact on their health: Obstructive sleep apnea (OSA) is a sleep breathing disorder (SBD) that can develop during pregnancy, particularly in the third trimester and for women who are obese.

Some women may have obstructive sleep apnea before they become pregnant, while others may develop the condition during pregnancy. Not only can obstructive sleep apnea interrupt sleep, but it is also associated with health problems like hypertension and an increased likelihood of a cesarean birth. Here’s what moms should know about obstructive sleep apnea, who is at risk, how it affects pregnancy and the fetus, and how it is diagnosed and treated.

What Is Obstructive Sleep Apnea?

Maternal OSA occurs when a pregnant woman experiences blockages in her upper airway, causing irregular breathing patterns. OSA is an under-diagnosed condition in the general population, but especially among pregnant women.4,6 Research has reported a broad range of prevalence rates, from 3.6 to 10.5 percent in early pregnancy and up to 26 percent in the third trimester. Development of OSA during pregnancy is caused by an increase in weight, uterine volume, elevation of the diaphragm, upper airway remodeling, and changes in hormones.4 These physical changes make pregnant women more susceptible to OSA.4

Who Is at Risk?

Risk factors for OSA are similar to those in the general population, but the odds of developing OSA are greater due to the physical changes of pregnancy.7 Risk factors for OSA during pregnancy include the following:

OSA incidence exceeds 10 percent in premenopausal women in the United States, and more women are entering pregnancy with preexisting OSA due to rising rates of obesity. Many pregnant women are unaware of how detrimental OSA can be for their health and for their unborn children.9 Patient awareness and education on the effects of maternal OSA are essential to ensure compliance with diagnostic procedures and treatments.

How Does Sleep Apnea Affect Pregnancy?

Pregnant women often have a hard time sleeping well due to the general discomfort that comes with pregnancy. When pregnant women also have obstructive sleep apnea, the sleep they get can be fragmented and less restful due to frequent awakening.

However, the effects of sleep apnea during pregnancy go beyond poor sleep. Pregnant women with OSA have a significantly higher risk of pregnancy-specific complications compared to pregnant women without OSA.3 Additional research is needed to establish a causal relationship between OSA and pregnancy complications. However, the following are potential medical consequences associated with OSA and pregnancy:

  • Gestational hypertensive conditions, including preeclampsia
  • Gestational diabetes
  • Surgical complications
  • Cesarean sections
  • Venous thromboembolism
  • Cardiomyopathy
  • Pulmonary edema
  • Congestive heart failure
  • Extended hospital stays
  • Higher rate of ICU admissions1,3

Gestational hypertension, preeclampsia, and diabetes are conditions consistently linked to maternal OSA, while many other conditions still require additional research.1,3 Meta-analyses (statistical analysis of multiple studies) found OSA increases the odds of gestational hypertension, preeclampsia, and gestational diabetes. Gestational hypertension is defined clinically as systolic BP≥140 mmHg and/or diastolic BP≥90 in a previously normotensive woman, and preeclampsia was defined as gestational hypertension with 24-hour urinary protein level >0.3 g.7 Pregnant women with OSA have a higher risk of preeclampsia even after adjusting for confounders such as body mass index.1 Preeclampsia and gestational diabetes significantly increase the risk of cardiovascular events later in life.3 

Due to the potential medical complications associated with OSA and pregnancy, OSA can have a significant impact on maternal mortality rates.4 One study found that pregnant women with obstructive sleep apnea were five times more likely to die during a pregnancy-related admission to the hospital. When educating pregnant patients with OSA, it is important to discuss potential health consequences for their unborn children as well.

How Does Maternal OSA Affect the Developing Fetus?

While most of the health impacts of obstructive sleep apnea are on the mother, studies have shown possible effects on the developing fetus as well. Potential medical consequences of OSA on the fetus include the following:

Additional research is necessary to establish a causal relationship between OSA and adverse fetal outcomes. However, multiple studies have found the fetus can experience developmental and medical complications due to maternal OSA. A study of over 1 million women published in Sleep Medicine in 2020 concluded that OSA can cause a higher risk of congenital anomalies.

Maternal OSA is also associated with 1.5 to twofold increased frequency of low birth weight and small for gestational age.3 Neonates born to mothers with OSA are also more likely to require resuscitation, intensive care unit admission, and longer hospital stays.2 When caring for pregnant patients with gestational hypertension and diabetes, it is especially important to consider OSA diagnostic tests to ensure a healthier and safer pregnancy for both the mother and fetus.

How Is Maternal OSA Diagnosed?

Routine screening, early diagnosis, and effective treatment of OSA are recommended in pregnant women, especially during mid and late pregnancy.5 Management of women with sleep apnea should be multidisciplinary and include specialists in sleep medicine, gynecology, obstetrics, and anesthesiology.3 The gold standard for the diagnosis of OSA is overnight, attended, in-lab polysomnography, particularly for women with suspected severe OSA.3

However, overnight studies can present challenges for patients—especially pregnant women, who may need to wake up frequently during the night to urinate. In order to facilitate easier diagnosis, home sleep apnea tests can be given to pregnant women. Home sleep apnea testing devices have been used in studies and been validated for pregnant women.3

How Is Maternal OSA Treated?

Definitive treatment guidelines do not exist for pregnant women with OSA. Since OSA risk factors for pregnant women are similar to the general population, existing treatment guidelines are often extrapolated to pregnant women.3 In the general population, continuous positive airway pressure (CPAP) is the preferred treatment for mild, moderate, and severe OSA.8

The American Academy of Sleep Medicine (AASM) recommends oral appliances for patients intolerant to CPAP therapy. For pregnant women with mild OSA, the cure can be as simple as changing their sleeping position. Positional OSA is more common in milder cases of OSA and usually resolves when pregnant women sleep on their side.9

Health care providers should never dismiss daytime fatigue and sleepless nights as symptoms of pregnancy. OSA during pregnancy is a serious condition that can adversely affect maternal and fetal health. Screening and testing for OSA can protect pregnant women and their unborn children from medical complications as well as lifelong health consequences. Treating obstructive sleep apnea can help expectant mothers sleep better and have healthy pregnancies.

To learn more about OSA and its symptoms, causes, and treatments, visit us at thevivosinstitute.com/blog.

 

 

References

  1. Bourjeily, G., Danilack, V. A., Bublitz, M. H., Lipkind, H., Muri, J., Caldwell, D. & Rosene-Montella, K. (2017). Obstructive sleep apnea in pregnancy is associated with adverse maternal outcomes: a national cohort. Sleep Medicine, 38, 50–57. doi:10.1016/j.sleep.2017.06.035
  2. Bourjeily, G., Danilack, V. A., Bublitz, M. H., Muri, J., Rosene-Montella, K., & Lipkind, H. (2020). Maternal obstructive sleep apnea and neonatal birth outcomes in a population based sample. Sleep Medicine, 66, 233–240. doi:10.1016/j.sleep.2019.01.019
  3. Dominguez, J. E., Street, L., & Louis, J. (2018). Management of obstructive sleep apnea in pregnancy. Obstetrics and Gynecology Clinics of North America, 45(2), 233–247. doi:10.1016/j.ogc.2018.01.001
  4. Louis, J. M., Mogos, M. F., Salemi, J. L., Redline, S., & Salihu, H. M. (2014). Obstructive sleep apnea and severe maternal-infant morbidity/mortality in the United States, 1998-2009. Sleep, 37(5), 843–849. doi:10.5665/sleep.3644
  5. Martin, H., Antony, K. M., & Kumar, S. (2020). Obstructive sleep apnea in pregnancy – development, impact and potential mechanisms. Journal of Women’s Health and Development, 03(04). doi:10.26502/fjwhd.2644-28840053
  6. Perkins, A., & Einion, A. (2019). Pregnant pause: should we screen for sleep disordered breathing in pregnancy? Breathe (Sheffield, England), 15(1), 36–44. doi:10.1183/20734735.0343-2018
  7. Pien, G. W., Pack, A. I., Jackson, N., Maislin, G., Macones, G. A., & Schwab, R. J. (2014). Risk factors for sleep-disordered breathing in pregnancy. Thorax, 69(4), 371–377. doi:10.1136/thoraxjnl-2012-202718
  8. Ramar, K., Dort, L. C., Katz, S. G., Lettieri, C. J., Harrod, C. G., Thomas, S. M., & Chervin, R. D. (2015). Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: An update for 2015: An American academy of sleep medicine and American academy of dental sleep medicine clinical practice guideline. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 11(7), 773–827. doi:10.5664/jcsm.4858
  9. Silvestri, R., & Aricò, I. (2019). Sleep disorders in pregnancy. Sleep Science (Sao Paulo, Brazil), 12(3), 232–239. doi:10.5935/1984-0063.20190098
  10. Teoh, A. N., Kaur, S., Mohd Shukri, N. H., Shafie, S. R., Ahmad Bustami, N., Takahashi, M., Lim, P. J., & Shibata, S. (2021). Psychological state during pregnancy is associated with sleep quality: preliminary findings from MY-CARE cohort study. Chronobiology international, 38(7), 959–970. doi:10.1080/07420528.2021.1902338