Review ArticleClinical Review

Sleep-Disordered Breathing During Pregnancy

Chakradhar Venkata and Saiprakash B. Venkateshiah
The Journal of the American Board of Family Medicine March 2009, 22 (2) 158-168; DOI: https://doi.org/10.3122/jabfm.2009.02.080057

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Figures

  • Figure 1.
    Figure 1.

    Recommendations for the evaluation and treatment of pregnant women suspected of having sleep-disordered breathing. AHI, apnea-hypopnea index; nCPAP, nasal continuous positive airway pressure; OSA, obstructive sleep apnea; PIH, pregnancy-induced hypertension; SaO2, arterial oxygen saturation. Modified from Pien GW et al.51

Tables

  • Table 1.

    Research Studies Evaluating Sleep-Disordered Breathing Among Pregnant Women

    AuthorYearNumber of PatientsStudy Design/MethodsResults/Conclusions
    Loube D et al (28)1996350 pregnant women and 110 nonpregnant controlsProspective, nonrandomized, questionnaire surveyFrequent snoring was reported in the pregnant women (14% vs 4%; P < .05). No increased risks of adverse fetal outcomes noted in snorers.
    Nikkola E et al (29)199610 womenCross-sectional study during the third trimester in women with multiple pregnanciesFour of 10 patients had increased respiratory resistance on PSGs at 30 to 36 weeks’ gestation. No obstructive or central sleep apneas or oxyhemoglobin desaturations were noted.
    Maasilta P et al (30)200111 obese pregnant women and 11 pregnant women with normal weightCase-control study comparing sleep-related breathing eventsAHI, 4% oxygen desaturations, and snoring times were more significant in obese pregnant women compared with patients of normal weight.
    Guilleminault C, et al (31)*200412 womenProspective study evaluating tolerance, compliance, and problems associated with nasal CPAP therapy during pregnancyAll patients tolerated CPAP therapy without complications and nightly compliance rate was 6.5 hours at 6 months of gestation. Nasal CPAP significantly improved all sleep questionnaire scales.
    Edwards N, et al (32)200510 pregnant womenCase-control, longitudinal study comparing severity of SDB and maternal blood pressure responses in late pregnancy to postpartumTen patients with OSA were treated with nasal CPAP, with withdrawal of therapy within 2 weeks after delivery. Sleep studies were repeated 3 months after delivery. There was a significant reduction in mean AHI values postnatally, along with significant improvement in arterial oxygen saturation and reduction in blood pressure.
    Izci B, et al (33)2005167 healthy pregnant women, 82 preeclamptic women, and 160 nonpregnant womenCross-sectional studySnoring and sleepiness increased in the third trimester of pregnancy, particularly in preecalmptic women. Nonpregnant women had lower mean Epworth sleepiness scores than both pregnant and preeclamptic groups (P < .001).
    Pien GW, et al (25)2005155 womenProspective study evaluating symptoms of SDB over the course of pregnancySDB symptoms and daytime somnolence increased significantly during pregnancy. Women with high baseline body mass indices and greater increases in neck circumference during pregnancy reported higher apnea symptom scores.
    Izci B, et al (7)2006100 women in third trimester were compared with equal number of nonpregnant counterpartsCross-sectional prospective study evaluating the effect of pregnancy on upper airway dimensionsAll 9 measures of upper airway caliber were smaller in pregnant women, out of which 4 dimensions were statistically significant. Three of the upper airway dimensions were significantly smaller in the third trimester of pregnancy compared with postpartum.
    Guilleminault C, et al (34)*200712 pregnant women with preecalmpsia risk factorsProspective, longitudinal study evaluating early intervention of nasal CPAP therapyEarly application of CPAP therapy alleviated sleep-related breathing disturbances but was not sufficient to prevent negative pregnancy outcomes.
    Sahin FK, et al (35)200835 pregnant women with self-reported symptoms of frequent snoring or apneaProspective, observational study assessing nonstress test changes during maternal desaturations and evaluating fetal outcomes in pregnant women with OSAFour (11.4%) women had OSA diagnosed by PSG. Three women had fetal heart rate decelerations accompanying maternal desaturations. The neonates of women with OSA had lower mean Apgar scores and birth weights. Three neonates of women with OSA required NHCU admission where as none of the babies born to women without OSA required the NHCU.

    • ↵* Studies evaluating the therapy of sleep-disordered breathing.

    • AHI, apnea-hypopnea index; CPAP, continuous positive airwaypressure; NHCU, newborn health care unit; OSA, obstructive sleep apnea; PSG,polysomnogram; SDB; sleep-disordered breathing.

  • Table 2.

    Research Studies Investigating Sleep-Disordered Breathing and Gestational Hypertension/Preeclampsia

    AuthorYearNumber of PatientsStudy Design/MethodsResults/Conclusions
    Edwards N, et al (36)*200011 womenProspective nonrandomized study of CPAP therapy in patients with severe preeclampsiaSleep-induced partial upper airflow limitation was noted in all patients on polysomnographic studies, which was eliminated with CPAP therapy along with blood pressure improvement.
    Franklin KA, et al (24)2000502 womenRetrospective, cross-sectional questionnaire survey done on the day of deliveryHabitual snoring increased significantly by late pregnancy (23% vs 4% before pregnancy). Incidence of gestational hypertension (14% vs 6%); preeclampsia (10% vs 4%); and fetal growth retardation (7.1% vs 2.6%) were significantly higher in pregnant women with habitual snoring compared with nonsnorers.
    Guilleminault C, et al (37)2000267 women in the first part of the study; 26 women in the second part of the studyProspective and cross-sectional study evaluating pregnancy-associated snoring and blood pressure52% of patients reported snoring at 6 months’ gestation compared with 37% at 6 weeks. Mean AHI and BP at 6 months’ gestation were slightly higher in snorers, but this data was not clinically or statistically significant. However, the absence of the normal nocturnal dip in systolic blood pressure was noted in snorers.
    Connolly G, et al (38)200175 women (15 women with preeclampsia, 15 from each trimester and 15 nonpregnant controls)Case control prospective study comparing inspiratory flow limitation during sleepPatients with preeclampsia spent more time during sleep with significant inspiratory flow limitation (31%) compared with normotensive third trimester patients (15.5%) and rest of the 3 groups (<5%).
    Edwards N, et al (39)200120 (10 normotensive pregnant women with OSA, 10 women with preeclampsia and OSA)Case-control study evaluating hemodynamic responses to obstructive respiratory events during sleepThe pressor responses to obstructive respiratory events during sleep were enhanced in preeclamptic patients compared with controls.
    Yinon D, et al (40)200617 women with preeclampsia were compared with 25 matched subjectsCase-control study evaluating sleep disordered breathing and endothelial dysfunctionWomen with preeclampsia had a significantly higher RDI (18.4 vs 8.3; P < .05) and lower endothelial function index (1.5 vs 1.8; P < .05) compared with controls.
    Poyares D, et al (41)*200716 pregnant women with hypertension and snoring (9 women in control group and 7 in the treatment group)Randomized control study comparing nasal CPAP treatment with standard prenatal careCPAP therapy added to standard prenatal care during early pregnancy improved blood pressure control without the need for escalating antihypertensive medication doses. However, infant outcomes seemed to be similar in both groups.

    • ↵* Studies evaluating therapy of sleep-disordered breathing.

    • AHI, apnea-hypopnea index; BP, blood pressure; CPAP, continuous positive airway pressure; OSA, obstructive sleep apnea; PSG, polysomnogram; RDI, respiratory disturbance index.

  • Table 3.

    Postpartum Recommendations for Women with Pregnancy-Associated Sleep Apnea51

    Initial Postpartum ManagementIf Symptoms Recur with Withdrawal of Therapy or Weight Gain Persists
    Mild to moderate pregnancy-associated sleep apneaPostpartum withdrawal of therapy with close follow-up for symptom recurrence; if asymptomatic, monitor for recurrence in future pregnanciesObtain overnight PSG to determine baseline AHI; assess need for treatment and therapeutic options based on findings
    Severe pregnancy-associated sleep apneaContinue therapy and obtain overnight PSG when weight within 10% to 15% of baseline to rule out persistent OSAObtain repeat overnight PSG to establish baseline AHI (consider split-night study with CPAP titration) and the need for continued therapy
    Preexisting sleep apneaConsider return to prepregnancy therapy when weight within 10% to 15% of baseline, with close follow-up for symptom recurrenceRepeat overnight PSG (with split-night study if using CPAP at baseline) to determine new baseline AHI; modify prepregnancy therapy based on findings

    • PSG, polysomnography; AHI, apnea-hypopnea index; OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure.

    • Reproduced with permission from Pien GW, Schwab RJ. Sleep disorders during pregnancy. Sleep 2004;27:1405–17.

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