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    Obstructive sleep apnea in pregnancy- what you need to know

    Introduction

    Sleep-disordered breathing (SDB) is a group of disorders characterized by abnormalities in ventilation and respiration. The spectrum ranges from snoring that is considered mild to the most severe form, obstructive sleep apnea (OSA).1 In the obstetric literature, the terms SDB and sleep apnea have been used interchangeably. OSA involves repetitive partial or complete pharyngeal collapse while sleeping, resulting in either apnea or hypopnea.2 These recurrent nocturnal hypoxic events result in arousal from sleep, sleep fragmentation and excessive daytime sleepiness.2-4 In this article we will review what is known about OSA, the associated morbidity and pregnancy management in affected pregnant women.

    Epidemiology

    In the largest prospective study published to date, among the 3,132 nulliparous women who completed objective testing for sleep apnea, prevalence of sleep apnea was estimated to be 3.6% in early pregnancy and increased across gestation with rates as high as 26% in the third trimester. That study confirmed the findings of Pien, et al, who found an increase from 10.5% in the first trimester to 26.7% in the third trimester among a group of women who underwent overnight polysomnography at 2 time points in pregnancy.5

    Risk factors for OSA in the general population are well-established and include obesity, older age, African-American race, craniofacial abnormalities, and smoking.6,7 Sleep apnea is associated with Type II diabetes, hypertension and cardiovascular disease.2 Women who have those risk factors before pregnancy may be at risk for sleep apnea. Existing small studies in pregnancy also demonstrate that increasing maternal age, obesity, chronic hypertension, and frequent snoring (> 3x/week) are risk factors for
    the condition.8-10

    Diagnosis

    Screening for OSA in pregnancy presents a unique challenge. The Berlin questionnaire, Epworth Sleepiness Scale and STOP-BANG questionnaires developed and validated in the general population have not been demonstrated to be useful in the obstetric population, with reported sensitivities and specificities of 36% to 39% and
    68% to 77%, respectively. 11-15

    The gold standard for diagnosis of sleep apnea is overnight polysomnography.4 However, the test is uncomfortable due to the use of many electrical leads and expensive and inconvenient because of the requirement for the patient to be away from home. Home sleep apnea testing using a portable sleep device presents a more comfortable, affordable and convenient alternative,  and it is being used increasingly (Figure 1).4 While home sleep testing is widely accepted, there are limitations, including potential underestimation of sleep apnea severity, which can result in false-negative results.4 If a patient has had a negative home sleep test, and significant clinical suspicion remains, it is recommended that she undergo overnight polysomnography.4

    Sleep apnea severity is scored based on the Apnea Hypopnea Index (AHI), a measure of how many apneas (cessation of airflow ≥ 10 seconds accompanied by an arousal or oxyhemoglobin desaturation) and hypopneas (reduction of airflow ≥ 10 seconds accompanied by an arousal or oxyhemoglobin desaturation) are present per hour of sleep. An AHI of 5 to less than 15 is considered mild, 15 to less than 30 is considered moderate, and 30 or greater is considered severe. OSA is defined as having an AHI of 5 or greater with evidence of daytime sleepiness.16

    NEXT: Treatment

    Judette Louis, MD, MPH
    Dr Louis is Assistant Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Morsani College of ...

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