Pregnant pause: should we screen for sleep disordered breathing in pregnancy?

Abstract

Physiological and hormonal changes in pregnancy can contribute towards sleep disordered breathing in pregnant women (SDBP). When present, SDBP increases the risk of several adverse maternal and fetal outcomes independent of factors such as age, weight and pre-existing maternal comorbidities. SDBP is underdiagnosed and may be hard to recognise because the presentation can be difficult to differentiate from normal pregnancy and the severity may change over the course of gestation. Timely intervention seems likely to help reduce adverse outcomes, but the relative benefits of intervention are still unclear. The definition of what constitutes a sleep-related breathing “disorder” in pregnancy may be different to the general population and so traditional thresholds for intervention may not be relevant in pregnancy. Any modifications to the disease definition in this group, or implementation of more intensive screening, may result in overdiagnosis. Further research is needed to help clinicians evaluate the balance of benefits and harms in this process. Until this is clearer there is a strong imperative for shared decision making in screening and treatment decisions, and screening programmes should be monitored to assess whether improved outcomes can be achieved at the healthcare system level.Key pointsUntreated sleep disordered breathing in pregnancy poses risks to maternal and fetal wellbeing, but it is underdiagnosed.Careful approaches to screening could improve rates of diagnosis, but thresholds for and benefits of intervention are unclear.Clinical guidelines and screening programmes for sleep disordered breathing in pregnancy need to consider the potential harms of overdiagnosis and should involve shared decision making and careful monitoring of outcomes relevant to the individual.Educational aimsExplore current knowledge of the prevalence of sleep disordered breathing in the pregnant population.Explore the relationship between sleep disordered breathing and adverse outcomes.Understand the approaches to diagnosis and management of sleep disordered breathing in pregnancy.Explore issues around screening, underdiagnosis and overdiagnosis in the context of sleep disordered breathing in pregnancy.

Management of allergic diseases in pregnancy

“…Increased blood volume, adipose tissue, rhinitis, and edema during pregnancy contribute to upper airway narrowing. 30,31 GERD (gastroesophageal reflux disease) is common in pregnant women because of decreased esophageal sphincter tone and decreased gastric motility. 31 Rhinitis occurs in about 65% of pregnant women with asthma and can be of the allergic and non-allergic type.…”

“…26 Sleep-disordered breathing in pregnancy (SDBP)/Obstructive sleep apnea syndrome (OSAS) is often underdiagnosed during pregnancy and may be a reason for poor asthma control and increases the risk of several adverse maternal and fetal outcomes. 30,32 Assessment of these comorbidities (such as obesity) and smoking history before and during pregnancy has the potential for preventive strategies to improve mothers' and their offspring's health. 33 The goals of asthma management in pregnancy are identical to the non-pregnant population: risk control and symptom reduction.…”

Sleep disordered breathing in pregnancy: A review of the pathophysiology of adverse pregnancy outcomes

“…In addition, questionnaires routinely used to quantify risk of SDB in the non‐pregnant population (eg the Epworth Sleepiness Scale, Berlin Questionnaire and STOP‐Bang Questionnaire) are not validated in pregnant women, and studies evaluating their predictive capacity in this setting have shown conflicting results . Furthermore, emerging evidence regarding an association between snoring and adverse pregnancy outcomes has led to debate surrounding the suitability of conventional SDB definitions and diagnostic thresholds during pregnancy . Therefore, despite the increasing pool of pregnant women at risk of SDB, the optimal method to identify those in whom further investigation or treatment is indicated remains unknown.…”

Too much or too little medicine? Overdiagnosis, underdiagnosis, overtreatment and undertreatment in respiratory diseases

“…Facts are not neutral; they are theory- and value-laden [5, 6], and different people may arrive at varying conclusions based on the same evidence. An article that examines the evidence for screening for sleep disordered breathing in pregnancy, challenges us as clinicians to communicate uncertainty in the evidence to patients [7]. An article giving a global perspective of over- and underdiagnosis of COPD highlights the seeming paradox that under- and overdiagnosis of COPD coexist in the same setting [8].…”