Sleep disordered breathing in pregnancy: the maternal and fetal implications

Abstract

Sleep disordered breathing (SDB) which includes obstructive sleep apnoea (OSA) and upper airway resistance syndrome (UARS), has emerged as a risk factor for adverse maternal-foetal outcomes in pregnancy. Physiological changes of pregnancy predispose a woman 'at risk' towards developing SDB. The increasing incidence of OSA in pregnancy closely correlates with the population trends of obesity. Common screening tools validated in non-pregnant subjects including Epworth Sleepiness Scale (ESS) and Berlin Questionnaire (BQ) are poor predictors of SDB in pregnancy. Preeclampsia, gestational hypertension and gestational diabetes mellitus (GDM) are linked with SDB. Preeclampsia and OSA share common pathological associations. It is unclear if one predisposes the other. Foetal morbidity includes intrauterine growth restriction (IUGR), preterm delivery, low birth weight, neonatal intensive care unit (NICU) admission and Apgar score of less than seven at one minute. Continuous positive airway pressure (CPAP) is a well-documented treatment of SDB in pregnancy and has been shown to reverse some of the adverse events. It becomes imperative to diagnose and manage this condition as OSA causes substantial morbidity in the untreated pregnant patient and foetus. Three short clinical cases and a literature review on SDB on pregnancy are presented.

Obstructive sleep apnoea in multiple pregnancy

“…Other data on OSA in multiple pregnancies has been published in case reports [21][22][23] (see Table 1). Further studies are required to evaluate the prevalence of OSA in multiple pregnancies, given the dynamic physiology of pregnancy screening at a single time point may underestimate the prevalence of this disorder, particularly as OSA is known to be more prevalent in the third trimester of singleton pregnancy.…”

“…Any tool developed to screen for OSA in pregnancy needs to assess proven risk factors for OSA in singleton pregnancies including snoring, elevated BMI and increased neck circumference; features that were also observed in three case reports [21][22][23] of OSA in twin pregnancies. Advanced maternal age has also been recently shown to increase the risk of OSA in singleton pregnancies, 27 and should therefore also be considered in future screening for OSA.…”

“…The successful use of PSG to diagnose OSA in multiple pregnancies has been documented. [21][22][23] More limited data can be obtained in the home setting; involving either reduced channel EEG or actigraphy (movement detection) as a proxy measure of sleep state. Home-based sleep studies may be more convenient, particularly as multiple pregnancies already require supplementary antenatal visits, therefore…”

“…30 In singleton pregnancies CPAP has been shown to improve symptoms 31 and reduce hypertension. 32 In two case reports involving CPAP in multiple pregnancies, CPAP controlled or reduced the effects of sleep apnoea, 21,23 whereas in a third case report supplemental oxygen and more complex non-invasive ventilation were required. 22 In each case, clinicians felt nocturnal ventilatory support improved pregnancy outcomes; however, this limited observational data highlights the need for further research.…”

Treatment of superimposed preeclampsia on chronic hypertension in a twin pregnancy with automatic continuous positive airway pressure: a case report

“…The aetiology and mechanism of OSA is multifactorial but is largely due to the interaction of an easily collapsible upper airway with the relaxation of the pharyngeal dilator muscles [6]. Obesity, advancement of age, alcohol intake, smoking, soft tissue hypertrophy, and craniofacial features such as retrognathia add to this tendency for collapse by increasing extraluminal tissue pressures surrounding the upper airway.…”