Can we predict sleep‐disordered breathing in pregnancy? The clinical utility of symptoms

Abstract

Sleep-disordered breathing (SDB) is reported commonly during pregnancy and is associated with an increased risk of adverse maternal and fetal outcomes, but the majority of these data are based upon self-report measures not validated for pregnancy. This study examined the predictive value of screening questionnaires for SDB administered at two time-points in pregnancy, and attempted to develop an 'optimized predictive model' for detecting SDB in pregnancy. A total of 380 women were recruited from an antenatal clinic in the second trimester of pregnancy. All participants completed the Berlin Questionnaire and the Multivariable Apnea Risk Index (MAP Index) at recruitment, with a subset of 43 women repeating the questionnaires at the time of polysomnog-raphy at 37 weeks' gestation. Fifteen of 43 (35%) women were confirmed to have a respiratory disturbance index (RDI) > 5 h À1. Prediction of an RDI > 5 h À1 was most accurate during the second trimester for both the Berlin Questionnaire (sensitivity 0.93, specificity 0.50, positive predictive value 0.50 and negative predictive value 0.93), and the MAP Index [area under the receiver operating characteristic (ROC) curve of 0.768]. A stepwise selection model identified snoring volume, a body mass index (BMI)≥32 kg m À2 and tiredness upon awakening as the strongest independent predictors of SDB during pregnancy; this model had an area under the ROC curve of 0.952. We conclude that existing clinical prediction models for SDB perform inadequately as a screening tool in pregnancy. The development of a highly predictive model from our data shows promise for a quick and easy screening tool to be validated for future use in pregnancy. IN TROD UCTI ON Self-reported symptoms of sleep-disordered breathing (SDB) such as snoring and witnessed obstructive apneas increase in frequency during pregnancy (Franklin et al., 2000; Pien et al., 2005); however, the accuracy of symptoms for detecting SDB in pregnancy is unclear. To date, there are no large studies that have confirmed a higher prevalence of SDB on polysomnography (PSG) among pregnant populations. The prevalence of SDB among pregnant women and the relationship of screening questionnaires to objectively confirmed SDB requires urgent clarification, given that preliminary studies suggest that SDB may increase the risk of adverse fetal and maternal outcomes, including hypertension, pre-eclampsia and impaired fetal growth (Bourjeily et al., 2010; Chen et al., 2011; Franklin et al., 2000). Clinical prediction models based on self-reported symptoms of SDB, along with demographic and anthropometric data, have been developed to identify and prioritize those at highest risk of having SDB. A number of prediction models for SDB have shown potential utility in clinical settings; however, they have been validated mainly in predominantly male and/or middle-aged populations (Chung et al., 2008; Netzer et al., 1999; Takegami et al., 2009), usually with suspected sleep difficulties (Maislin et al., 1995). Only two studies have commented on the pr...

Obstructive sleep apnea in pregnancy: reliability of prevalence and prediction estimates

“…After this study was initiated, Facco, et al , demonstrated that the BQ has a sensitivity and specificity of 39% and 68%, respectively, while the ESS has a sensitivity and specificity of 36% and 77%, respectively(9). One recent study found a much higher sensitivity and specificity of the BQ among gravidae, but only performed diagnostic testing on women who either did not score as "high risk" in any of the three categories of the BQ or scored as "high risk" in all three categories(10). Thus the sensitivity and specificity in their study may have limited clinical utility among a population with more intermediate scores, or prone to confounding by virtue of inclusion of obesity on the BQ.…”

Obstructive sleep apnea in pregnancy: performance of a rapid screening tool

“…However, none of the tools accurately detected OSA during the third trimester, with sensitivities between 14.6 and 33.3%. Wilson and colleagues [12] also found that the BQ had limited predictive abilities, with a sensitivity and specificity of 0.87 and 0.32, respectively. Based on the above evidence, currently available tools may not be optimal in screening for OSA during pregnancy.…”

“…These questionnaires include the Epworth Sleepiness Scale (ESS), the Berlin Questionnaire (BQ), and STOP-BANG Questionnaire. However, studies have found poor predictive values for the ESS [9–12], BQ [3, 9–11], and STOP-BANG [11] in pregnant women. A recent meta-analysis also found that the BQ and ESS performed poorly in predicting OSA during pregnancy, and recommended developing a new tool [13].…”

“…The Multivariable Apnea Prediction (MAP) Index is another widely used screening tool for OSA that has been used in pregnancy studies [12, 14]. One of the subscales of the MAP Index is the Sleep Apnea Symptom Score (SASS).…”

“…There is a clear need to examine the predictive value of the SASS at different trimesters. Wilson and colleagues [12] tested the predictive values of MAP Index among 43 pregnant women. The researchers reported that the MAP Index demonstrated acceptable predictive values.…”