Sleep-related breathing disorders during pregnancy

What they are

Obstructive Sleep Apnea (OSA) is the most common type of sleep-related breathing disorder (SRBD) and is characterized by repeated airway closure, commonly associated with snoring, often accompanied by sensations of "choking" and "gasping" during the night. This leads to decreased blood oxygen levels, frequent awakenings, and increased blood pressure and heart rate during sleep (Sommers, 1995).

Prevalence

The prevalence of OSA in the general population ranges from 4% to 32% (Young, 2002; Tufik, 2010; Peppard, 2013; Heinzer, 2015). However, approximately 93% of men and 83% of women with moderate to severe apnea remain undiagnosed (Young, 1997). In women of reproductive age, obstructive sleep apnea presents with few symptoms, making diagnosis difficult. Physiological, anatomical, and hormonal changes during pregnancy may predispose women to the onset of SRBDs or worsen a pre-existing, undiagnosed condition (Facc, 2012; Hedman, 2002).

The prevalence of OSA during pregnancy remains uncertain in international literature and appears to be related to population type, ethnicity, pregnancy risk level (low or high), and gestational period (Fung, 2013; Wilson, 2013). High-risk pregnancy is defined as “one in which the life or health of the mother and/or fetus and/or newborn is more likely to be affected than in the average population,” with high-risk factors including obesity, hypertension, diabetes, maternal age at pregnancy onset, general clinical conditions, and pregnancy-related diseases such as gestational hypertension, preeclampsia, gestational diabetes, among others (CALDEYRO-BARCIA, 1973; High-Risk Pregnancy Manual, Brazilian Ministry of Health, 2017). Some studies show a prevalence of 20% to 35% of SRBDs in high-risk pregnant women (Antony, 2014).

Cause

Recent studies indicate that SRBDs characterized by sleep apnea, snoring, and nighttime respiratory effort—even in the absence of apnea—are associated with maternal and fetal consequences including gestational hypertensive disease (GHD), preeclampsia, gestational diabetes (GDM), and premature low birth weight infants (Guillemineault, 2007; Pamidi, S, 2014; Xu T, 2014).

Diagnosis

Diagnosing SRBDs during pregnancy can help prevent and treat these disorders early, reducing undesirable outcomes. To date, there are no guidelines standardizing or directing the early diagnosis and treatment of SRBDs during pregnancy, despite their potential harmful effects on both mother and fetus. Overnight polysomnography is the test used to diagnose sleep disorders. However, the long wait time for the exam, the limited diagnostic window during pregnancy, the discomfort caused by the sleep test in this population, and the general lack of awareness—both among the public and medical professionals—make investigation difficult or even impossible.

Treatment

CPAP, which is characterized as an airflow generator that maintains continuous positive airway pressure during sleep through a nasal mask, promotes full opening of the collapsed airway region and is the treatment of choice for moderate to severe sleep apnea (Kushida, 2006). CPAP is also indicated for the treatment of sleep-related breathing disorders (SRBDs) in the early stages of pregnancy and is well tolerated in this group (Guilleminault, 2004). However, adherence to CPAP during pregnancy has never been studied (Cornelio, 2016). Recent research using nighttime ventilation in pregnant women with preeclampsia or chronic hypertension has shown a reduction in blood pressure during sleep in preeclamptic women, improved blood pressure control during pregnancy in previously hypertensive patients without the need to change antihypertensive medication, and improved clinical outcomes at birth (Guilleminault, 2004; Guilleminault, 2007; Poyares, 2007).

Studies also show that in pregnant women at increased risk for OSA, treatment with CPAP improves maternal-fetal respiratory conditions. Furthermore, CPAP at low pressures during sleep could serve as an adjunct treatment for all women with gestational hypertension, preeclampsia, and snoring associated with sleep-related breathing difficulties (Guilleminault, 2004; Guilleminault, 2007; Poyares, 2007; Cornelio, 2016).

References

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10. Fung AM, Wilson DL, Lappas M, Howard M, Barnes M, O'Donoghue F, et al. Effects of maternal obstructive sleep apnoea on fetal growth: a prospective cohort study. PLoS One 2013;8(7).

11. CALDEYRO-BARCIA, R. et al. Fetal heart rate and acid-base balance. Montevideo: Latin American Center for Perinatology and Human Development, 1973. (CLAP Scientific Publication, No. 519).

12. High-Risk Pregnancy: Technical Manual / Ministry of Health, Secretariat of Health Care, Department of Strategic Programmatic Actions. – 5th ed. – Brasília: Ministry of Health Publishing House, 2010. 302 p. – (Series A. Standards and Technical Manuals)

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21. Guilleminault C, Palombini L, Poyares D, Takaoka S, Huynh NT, El-Sayed Y. Pre-eclampsia and nasal CPAP: part 1. Early intervention with nasal CPAP in pregnant women with risk-factors for pre-eclampsia: preliminary findings. Sleep Med 2007;9(1):9e14.

22. Poyares D, Guilleminault C, Hachul H, Fujita L, Takaoka S, Tufik S, et al. Preeclampsia and nasal CPAP: part 2. Hypertension during pregnancy, chronic snoring, and early nasal CPAP intervention. Sleep Med 2007;9(1):15e21.

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By Einstein Editorial Board