Maternal and neonatal morbidities associated with obstructive sleep apnea complicating pregnancy

doi:10.1016/j.ajog.2009.10.867

American Journal of Obstetrics and Gynecology

Volume 202, Issue 3, March 2010, Pages 261.e1-261.e5

Presented at the 29th Annual Meeting of the Society for Maternal-Fetal Medicine, San Diego, CA, Jan. 26-31, 2009.

https://doi.org/10.1016/j.ajog.2009.10.867 Get rights and content

Objective

The objective of the study was to estimate the maternal and neonatal morbidities associated with obstructive sleep apnea (OSA) in pregnancy.

Study Design

Women delivering between 2000–2008 with confirmed OSA in an academic center were included. Normal-weight and obese controls were randomly selected at a 2:1 ratio. Maternal and neonatal morbidities were compared between the groups. Multivariate analyses were performed to evaluate maternal morbidity and preterm birth (PTB).

Results

The analysis included 57 pregnancies complicated by OSA. Compared with normal-weight (n = 114) controls, OSA patients had more preeclampsia (PET) (19.3% vs 7.0%; P = .02) and PTB (29.8% vs 12.3%; P = .007). Controlling for comorbid conditions, OSA was associated with an increased risk of PTB (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.02–6.6), mostly secondary to PET (63%). Cesarean delivery (OR, 8.1; 95% CI, 2.9–22.1) and OSA were associated with maternal morbidity (OR, 4.6; 95% CI, 1.5–13.7).

Conclusion

Pregnancies complicated by OSA are at increased risk for preeclampsia, medical complications, and indicated PTB.

Section snippets

Materials and Methods

This was a retrospective cohort study of women with a confirmed diagnosis of OSA who received their prenatal care at our urban tertiary care center and delivered between January 2000–December 2008. Comparative cohorts of obese (prepregnancy BMI of ≥30 kg/m²) and normal-weight (prepregnancy BMI 18–24 kg/m²) women without OSA, matched for year of delivery, were randomly selected in a 2:1 fashion for each OSA case using our electronic perinatal database in a masked fashion with random number

Results

There were 68 pregnancies among 57 women with OSA. The first pregnancy with outcome information was selected for those with more than 1 pregnancy. The diagnosis of OSA was made before pregnancy in 33 women (58%). The remainder was diagnosed during pregnancy. All women diagnosed with OSA were recommended to use CPAP therapy, although compliance data were not available.

The median AHI was 22 (interquartile range, 12–44) events per hour. The median lowest O₂ saturation during an event was 87%

Comment

In this retrospective study, we found that OSA was associated with an increased risk of preterm delivery and maternal morbidity. Among the OSA group, the majority of preterm deliveries were the result of maternal or fetal indications rather than from spontaneous labor or membrane rupture.

Published case reports have implicated OSA as a potential contributor to maternal complications.⁶ To date, however, there are no large studies of pregnancy outcomes in women with OSA. To our knowledge this is

References (22)

N.M. Al Lawati et al.
Epidemiology, risk factors, and consequences of obstructive sleep apnea and short sleep duration
Prog Cardiovascular Dis
(2009)
H.M. Ehrenberg et al.
Prevalence of maternal obesity in an urban center
Am J Obstet Gynecol
(2002)
F. Kapsimalis
Obstructive sleep apnea in pregnancy
Sleep Med Clin
(2007)
K.A. Franklin et al.
Snoring, pregnancy-induced hypertension, and growth retardation of the fetus
Chest
(2000)
R.N. Aurora et al.
Sleep apnea and metabolic dysfunction: cause or co-relation?
Sleep Med Clin
(2007)
N.A. Collop et al.
Gender differences in sleep and sleep-disordered breathing
Clin Chest Med
(2004)
V.K. Somers et al.
Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing, in collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health)
Circulation
(2008)
V. Kapur et al.
Underdiagnosis of sleep apnea syndrome in US communities
Sleep Breath
(2002)
D.L. Katz et al.
Public health strategies for preventing and controlling overweight and obesity in school and worksite settings: a report on recommendations of the Task Force on Community Preventive Services
MMWR Recomm Rep
(2005)

J.M. Roberts et al.

Summary of the NHLBI Working Group on Research on Hypertension during Pregnancy

Hypertension

(2003)

Cited by (147)

Care plan for individuals at risk for preeclampsia: shared approach to education, strategies for prevention, surveillance, and follow-up
2023, American Journal of Obstetrics and Gynecology
Preeclampsia is a multisystemic disorder of pregnancy that affects 250,000 pregnant individuals in the United States and approximately 10 million worldwide per annum. Preeclampsia is associated with substantial immediate morbidity and mortality but also long-term morbidity for both mother and offspring. It is now clearly established that a low dose of aspirin given daily, beginning early in pregnancy modestly reduces the occurrence of preeclampsia. Low-dose aspirin seems safe, but because there is a paucity of information about long-term effects on the infant, it is not recommended for all pregnant individuals. Thus, several expert groups have identified clinical factors that indicate sufficient risk to recommend low-dose aspirin preventive therapy. These risk factors may be complemented by biochemical and/or biophysical tests that either indicate increased probability of preeclampsia in individuals with clinical risk factors, or more importantly, identify increased likelihood in those without other evident risk. In addition, the opportunity exists to provide this population with additional care that may prevent or mitigate the short- and long-term effects of preeclampsia. Patient and provider education, increased surveillance, behavioral modification, and other approaches to improve outcomes in these individuals can improve the chance of a healthy outcome. We assembled a group with diverse, relevant expertise (clinicians, investigators, advocates, and public and private stakeholders) to develop a care plan in which providers and pregnant individuals at risk can work together to reduce the risk of preeclampsia and associated morbidities. The plan is for care of individuals at moderate to high risk for developing preeclampsia, sufficient to receive low-dose aspirin therapy, as identified by clinical and/or laboratory findings. The recommendations are presented using the GRADE methodology with the quality of evidence upon which each is based. In addition, APPENDIX A, APPENDIX B with concise summaries of the care plan’s recommendations for patients and healthcare providers are provided. We believe that this shared approach to care will facilitate prevention of preeclampsia and its attendant short- and long-term morbidity in patients identified as at risk for development of this disorder.
The influence of maternal sleep disorders on fetal and neonatal outcome
2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second Edition
Sleep disruption is common during pregnancy, particularly in later stages of gestation, and is related to the hormonal and physiological changes that are experienced. Although pregnancy often exacerbates pre-existing sleep disturbance, it can also cause emergence of new ones. Clinical sleep disorders and behavioral practices can alter the structure and/or duration of typical sleep patterns, which in turn can impact the wellbeing of the maternal-fetal dyad. Sleep is also influenced by circadian rhythms, for example shift work results in circadian misalignment with some shift workers experiencing insomnia symptoms and poor sleep quality. Notably, shift work as an extreme example of circadian misalignment has been reported to impact fertility and early pregnancy loss. There are robust data regarding associations between sleep—particularly sleep-disordered breathing—and maternal outcomes such as gestational hypertension/pre-eclampsia and gestational diabetes, although less is known about how maternal sleep affects fetal wellbeing.
Sleep-disordered breathing in high-risk pregnancies is associated with elevated arterial stiffness and increased risk for preeclampsia
2022, American Journal of Obstetrics and Gynecology
Impaired vascular function is a central feature of pathologic processes preceding the onset of preeclampsia. Arterial stiffness, a composite indicator of vascular health and an important vascular biomarker, has been found to be increased throughout pregnancy in those who develop preeclampsia and at the time of preeclampsia diagnosis. Although sleep-disordered breathing in pregnancy has been associated with increased risk for preeclampsia, it is unknown if sleep-disordered breathing is associated with elevated arterial stiffness in pregnancy.
This prospective observational cohort study aimed to evaluate arterial stiffness in pregnant women, with and without sleep-disordered breathing and assess the interaction between arterial stiffness, sleep-disordered breathing, and preeclampsia risk.
Women with high-risk singleton pregnancies were enrolled at 10 to 13 weeks’ gestation and completed the Epworth Sleepiness Score, Pittsburgh Sleep Quality Index, and Restless Legs Syndrome questionnaires at each trimester. Sleep-disordered breathing was defined as loud snoring or witnessed apneas (≥3 times per week). Central arterial stiffness (carotid-femoral pulse wave velocity, the gold standard measure of arterial stiffness), peripheral arterial stiffness (carotid-radial pulse wave velocity), wave reflection (augmentation index, time to wave reflection), and hemodynamics (central blood pressures, pulse pressure amplification) were assessed noninvasively using applanation tonometry at recruitment and every 4 weeks from recruitment until delivery.
High-risk pregnant women (n=181) were included in the study. Women with sleep-disordered breathing (n=41; 23%) had increased carotid-femoral pulse wave velocity throughout gestation independent of blood pressure and body mass index (P=.042). Differences observed in other vascular measures were not maintained after adjustment for confounders. Excessive daytime sleepiness, defined by Epworth Sleepiness Score >10, was associated with increased carotid-femoral pulse wave velocity only in women with sleep-disordered breathing (P_interaction=.001). Midgestation (first or second trimester) sleep-disordered breathing was associated with an odds ratio of 3.4 (0.9–12.9) for preeclampsia, which increased to 5.7 (1.1–26.0) in women with sleep-disordered breathing and hypersomnolence, whereas late (third-trimester) sleep-disordered breathing was associated with an odds ratio of 8.2 (1.5–39.5) for preeclampsia.
High-risk pregnant women with midgestational sleep-disordered breathing had greater arterial stiffness throughout gestation than those without. Sleep-disordered breathing at any time during pregnancy was also associated with increased preeclampsia risk, and this effect was amplified by hypersomnolence.
Editorial for A randomized controlled trial of sleep study surveillance with targeted autoregulated positive airway pressure therapy for obstructive sleep apnea in pregnancy
2022, American Journal of Obstetrics and Gynecology MFM
Sleep disturbances during pregnancy and adverse maternal and fetal outcomes: A systematic review and meta-analysis
2021, Sleep Medicine Reviews
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 were 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 y 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.
Feasibility of a pilot, randomized controlled trial using a personalized health monitoring device with pregnant women for behavioral sleep research
2020, Applied Nursing Research
Sleep disruptions are common in pregnancy and can have significant maternal and infant health consequences. Management of sleep using a personal health monitoring (PHM) device may be effective in promoting behavior change and contribute to improved pregnancy-related sleep. The purpose of this pilot, randomized controlled trial was to determine the feasibility of recruitment (i.e., recruiting a 20% minority sample, most successful recruitment methods), retention, adherence, and data collection methods with a sample of pregnant women (n = 24) at 24 weeks gestation for a 12-week intervention using a PHM device. Of 24 enrolled participants, 20 (83%) were retained through the 12-week intervention and the follow-up at 2–4 weeks postpartum. The majority of participants had a four-year education and identified as White. Ninety-one percent (n = 11) wore the device for at least ten weeks. Pregnant women may be willing engage in sleep intervention research and wear a PHM to self-monitor sleep during pregnancy. Future research should consider recruitment methods tailored to recruit diverse populations of pregnant women.

View all citing articles on Scopus

: Reprints not available from the authors.

: Cite this article as: Louis JM, Auckley D, Sokol RJ, et al. Maternal and neonatal morbidities associated with obstructive sleep apnea complicating pregnancy. Am J Obstet Gynecol 2010;202:261.e1-5.

View full text

ResearchObstetricsMaternal and neonatal morbidities associated with obstructive sleep apnea complicating pregnancy

Objective

Study Design

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

Prog Cardiovascular Dis

Am J Obstet Gynecol

Sleep Med Clin

Chest

Sleep Med Clin

Clin Chest Med

Circulation

Underdiagnosis of sleep apnea syndrome in US communities

Sleep Breath

Public health strategies for preventing and controlling overweight and obesity in school and worksite settings: a report on recommendations of the Task Force on Community Preventive Services

MMWR Recomm Rep

Summary of the NHLBI Working Group on Research on Hypertension during Pregnancy

Hypertension

Research
Obstetrics
Maternal and neonatal morbidities associated with obstructive sleep apnea complicating pregnancy