Hypertension, fetal growth restriction and obstructive sleep apnoea in pregnancy

doi:10.1016/j.ejogrb.2008.07.009

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 141, Issue 1, November 2008, Pages 35-38

https://doi.org/10.1016/j.ejogrb.2008.07.009 Get rights and content

Abstract

Objective

To test the hypothesis that obstructive sleep apnoea (OSA) is more common in pregnancies complicated by hypertensive disease and fetal growth restriction.

Study design

An observational study comparing pregnant women with these two complications with normal pregnant women and non-pregnant women in two UK maternity hospitals. Each participant completed a sleep apnoea questionnaire and underwent nocturnal oxygen saturation monitoring.

Results

Using a strict definition of obstructive sleep apnoea confirmed by oxygen saturation monitoring only two mild cases were seen, 0/50 non-pregnant women, 1/69 of normal pregnant women, 0/48 women with various types of hypertensive disease, and 1/33 women carrying fetuses affected with fetal growth restriction. Even using less strict definitions and self-reported sleepiness scores there was no relation between sleep apnoea and either fetal growth restriction or hypertensive diseases.

Conclusion

Obstructive sleep apnoea is at most a rare cause of either growth restriction or hypertensive disease in pregnancy.

Section snippets

Objective

The cause of most cases of hypertensive disease in pregnancy and fetal intra-uterine growth restriction (IUGR) is unknown, but some cases may be related to unrecognised maternal obstructive sleep apnoea (OSA). There have been at least 10 well-documented cases of obstructive sleep apnoea in pregnancy [1], [2] of which four were clearly growth restricted. The remainder appeared appropriately grown, although correction for maternal weight was not made. Four women also suffered from pre-eclampsia.

Methods

The study was approved by the Nottingham local research ethics committee. Pregnant women were invited to participate in two hospitals between October 2004 and October 2006. The study was an observational comparison of the rate of sleep apnoea measured by both self-completed questionnaire and nocturnal oxygen saturation monitoring between pregnant women with hypertension or carrying a growth restricted fetus and normal pregnant women. For comparison a group of non-pregnant women were also

Results

178 pregnant women and 50 non-pregnant healthy control women were recruited. Their clinical features are shown in Table 1. A fully evaluable oximetry trace was obtained in all the non-pregnant women but in only 150 of the pregnant women. In 28 of the latter group the trace was not evaluable. The Epworth score was completed and analysable in all the pregnant participants but in one of the non-pregnant participants the Epworth score went missing.

Prior to assessment the pregnant women were

Discussion

This is the first systematic study measuring the relationship between sleep apnoea and hypertensive disease of pregnancy or fetal growth restriction. We found no relation between obstructive sleep apnoea defined according to current standard criteria and either outcome. The absence of association with apnoeas defined at the lower threshold suggests that this finding has not arisen from under-recognition of relatively mild disease. Our findings do not exclude the possibility that sleep apnoea

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Sleep disordered breathing is extremely common in pregnancy and is a risk factor for maternal complications. Animal models demonstrate that intermittent hypoxia causes abnormal fetal growth. However, there are conflicting data on the association between maternal sleep disordered breathing and offspring growth in humans. We investigated this association by conducting a systematic review and meta-analysis. Sixty-three manuscripts, and total study population of 67, 671, 110 pregnant women were included. Thirty-one studies used subjective methods to define sleep disordered breathing, 24 applied objective methods and eight used international codes. Using a random effects model, habitual snoring, defined by subjective methods, and obstructive sleep apnea, diagnosed by objective methods, were associated with an increased risk for large for gestational age (OR 1.46; 95%CI 1.02–2.09 and OR 2.19; 95%CI 1.63–2.95, respectively), while obstructive sleep apnea, identified by international codes, was associated with an increased risk for small for gestational age newborns (OR 1.28; 95%CI 1.02–1.60). Our results support that maternal sleep disordered breathing is associated with offspring growth, with differences related to the type of disorder and diagnostic methods used. Future studies should investigate underlying mechanisms and whether treatment of sleep disordered breathing ameliorates the neonatal growth.
Sleep disturbances during pregnancy and adverse maternal and fetal outcomes: A systematic review and meta-analysis
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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.
Maternal sleep during pregnancy and poor fetal outcomes: A scoping review of the literature with meta-analysis
2018, Sleep Medicine Reviews
Citation Excerpt :
However, these findings remain to be demonstrated in a large prospective study. Most of the non-epidemiological studies (with sample sizes less than n = 230 women) that reported FGR did not find a relationship with OSA [46–53]. Although in the largest published prospective study to date, Pamidi et al. [36] have recently reported that there is 2–3 fold increase in the odds of SGA at various thresholds of OSA severity (OR 2.65; 95% CI 1.15–6.10; p = 0.02).
There is a wealth of evidence to say that sleep impacts maternal health during pregnancy, however, little has been published on fetal health and maternal sleep. This scoping review summarises current literature on maternal sleep including sleep disordered breathing, sleep quality, sleep duration and supine sleep position, as these relate to fetal outcomes specifically birth weight, growth, preterm birth and stillbirth.
An overall interpretation of the studies evaluated shows that events occurring during maternal sleep such as obstructive sleep apnea, sleep disruption and sleep position may have a negative effect on the fetus resulting in altered growth, gestational length and even death. These effects are biologically and physically plausible.
In conclusion, there is limited and often conflicting information on maternal sleep and fetal outcomes. However, existing evidence suggests that this is an important area for future research. This area is ripe for investigation if there is to be reduction in the physical, emotional, and financial burden of poor fetal outcomes related to maternal sleep.
Performance of screening questionnaires for obstructive sleep apnea during pregnancy: A systematic review and meta-analysis
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After thorough screenings, 31 studies were included in the qualitative assessment, but only 6 studies were eligible for the meta-analysis [9–14]. Characteristics of included studies are summarized in Table 1, and reasons for exclusion of studies are summarized in Table S2 [15,19,20,36–57]. Among the 6 studies, 4 studies enrolled subjects through out-patient antenatal care services (ANC) [9,11–13], whereas 1 study enrolled subjects during obstetric admission [10] and 1 study enrolled subjects both during in-patient and ANC visits [14].
This review aims to evaluate the performance of obstructive sleep apnea (OSA) screening questionnaires during pregnancy. A systematic review and meta-analysis was performed using MEDLINE Scopus, CINAHL, and the Cochrane library. A bivariate meta-analysis was applied for pooling of diagnostic parameters. Six of the total 4719 articles met the inclusion criteria. The Berlin questionnaire (BQ, N = 604) and Epworth sleepiness scale (ESS, N = 420) were the most frequently used screening tools during pregnancy. The pooled prevalence of OSA during pregnancy was 26.7% (95%CI: 16.9%, 34.4%, I² = 83.15%). BQ performance was poor to fair with pooled sensitivity and specificity of 0.66 (95%CI: 0.45, 0.83; I² = 78.65%) and 0.62 (95%CI: 0.48, 0.75; I² = 81.55%), respectively. BQ performance was heterogeneous depending on type of reference test and pregnancy. Sensitivity increased if diagnosis was based on polysomnography (0.90), and respiratory disturbance index (0.90). However, sensitivity decreased if screening was performed in early pregnancy (≤20 weeks gestation: 0.47), and high-risk pregnancy (0.44). Performance of ESS was poor with pooled sensitivity and specificity of 0.44 (95%CI: 0.33, 0.56; I² = 32.8%) and 0.62 (95%CI: 0.48, 0.75; I² = 81.55%), respectively. In conclusion, BQ and ESS showed poor performance during pregnancy, hence a new OSA screening questionnaire is needed.
Registration: PROSPERO registration CRD42015025848.
Imitators of preeclampsia: A review
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The Epworth Sleepiness Scale and Berlin Questionnaire overestimate the prevalence of OSA in pregnancy when used as screening tool [42]. Overnight oximetry is not a useful indicator of OSA in pregnancy [43]. To date no studies have evaluated the impact of CPAP on maternal and fetal outcomes in women with OSA in pregnancy.
The effect of maternal sleep-disordered breathing on the infant's neurodevelopment
2015, American Journal of Obstetrics and Gynecology
We sought to examine the effect of maternal sleep-disordered breathing (SDB) on infant general movements (GMs) and neurodevelopment.
Pregnant women with uncomplicated full-term pregnancies and their offspring were prospectively recruited from a community and hospital low-risk obstetric surveillance. All participants completed a sleep questionnaire on second trimester and underwent ambulatory sleep evaluation (WatchPAT; Itamar Medical, Caesarea, Israel). They were categorized as SDB (apnea hypopnea index >5) and controls. Infant GMs were assessed in the first 48 hours and at 8-11 and 14-16 weeks of age. At 12 months of age the Infant Developmental Inventory and the Brief Infant Sleep Questionnaire were administered.
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Our preliminary results suggest that maternal SDB during pregnancy has no adverse effect on neonatal and infant neuromotor development but may affect social development at 1 year.

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Hypertension, fetal growth restriction and obstructive sleep apnoea in pregnancy

Abstract

Objective

Study design

Results

Conclusion

Section snippets

Objective

Methods

Results

Discussion

Br J Obstet Gynaecol

Chest

Eur J Obstet Gynecol Reprod Biol

Obstructive sleep apnoea in pregnancy

Obstet Gynecol Surv

Obstructive sleep apnoea (OSA)—implications in maternal–fetal medicine. A hypothesis

Med Hypotheses

Sleep disordered breathing and pregnancy

Thorax

Self-reported snoring in pregnancy. Association with fetal outcome

Chest

A clinical study of pre-eclampsia. Part 1

J Obstet Gynaecol Br Emp

Charts of fetal size. 3. Abdominal measurements

Br J Obstet Gynaecol