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Semin Neurol 2017; 37(06): 661-668
DOI: 10.1055/s-0037-1608843
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Sleep Disorders in Pregnancy

Mihaela Bazalakova
1   Department of Neurology, Wisconsin Institute for Sleep and Consciousness, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin
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Publication History

Publication Date:
21 December 2017 (online)

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Abstract

Sleep and pregnancy are dynamic processes with unique and evolving physiological substrates. Given the “restorative hypothesis” of sleep as an anabolic process essential for cellular and tissue regeneration, the largely unexplored role of sleep in gestational physiology and pregnancy outcomes promises to be a fascinating topic. Emerging literature suggests that objectively measured or self-reported short sleep duration may be a risk for adverse pregnancy outcomes, including gestational diabetes mellitus (GDM), gestational hypertension, and cesarean delivery. In this review, we discuss obstructive sleep apnea (OSA) and restless legs syndrome (RLS), two sleep disorders prevalent in pregnancy. OSA is especially likely in high-risk pregnancy where it is associated with comorbid cardiovascular and metabolic disturbances. We review new data strongly suggesting that OSA is an independent risk factor for GDM and gestational hypertension. It remains to be seen if sleep disruption, whether or not in the context of gestational RLS and gestational OSA, is a modifiable factor for adverse pregnancy outcomes. Clinicians are encouraged to query sleep symptoms in pregnant women and to have a low threshold to pursue investigations for OSA, including the subjective symptoms of snoring, witnessed apneas, and daytime sleepiness, and also medical comorbidities, such as chronic hypertension.

Keywords

sleep - pregnancy - gestational - apnea - restless legs syndrome - outcomes
 

  • References

  • 1 Rechtschaffen A, Gilliland MA, Bergmann BM, Winter JB. Physiological correlates of prolonged sleep deprivation in rats. Science 1983; 221 (4606): 182-184
    CrossrefPubMedGoogle Scholar
  • 2 Bergmann BM, Everson CA, Kushida CA. , et al. Sleep deprivation in the rat: V. Energy use and mediation. Sleep 1989; 12 (01) 31-41
    CrossrefPubMedGoogle Scholar
  • 3 Everson CA. Sustained sleep deprivation impairs host defense. Am J Physiol 1993; 265 (5 Pt 2): R1148-R1154
    PubMedGoogle Scholar
  • 4 Tononi G, Cirelli C. Sleep and the price of plasticity: from synaptic and cellular homeostasis to memory consolidation and integration. Neuron 2014; 81 (01) 12-34
    CrossrefPubMedGoogle Scholar
  • 5 Xie L, Kang H, Xu Q. , et al. Sleep drives metabolite clearance from the adult brain. Science 2013; 342 (6156): 373-377
    CrossrefPubMedGoogle Scholar
  • 6 Adam K, Oswald I. Protein synthesis, bodily renewal and the sleep-wake cycle. Clin Sci (Lond) 1983; 65 (06) 561-567
    CrossrefPubMedGoogle Scholar
  • 7 Sassin JF, Parker DC, Mace JW, Gotlin RW, Johnson LC, Rossman LG. Human growth hormone release: relation to slow-wave sleep and sleep-walking cycles. Science 1969; 165 (3892): 513-515
    CrossrefPubMedGoogle Scholar
  • 8 Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Sleep 2004; 27 (07) 1255-1273
    CrossrefPubMedGoogle Scholar
  • 9 Driver HS, Shapiro CM. A longitudinal study of sleep stages in young women during pregnancy and postpartum. Sleep 1992; 15 (05) 449-453
    CrossrefPubMedGoogle Scholar
  • 10 Bazalakova M, Bianchi MT, Stanic AK. Sleep deprivation and pregnancy. In: Bianchi MT. , ed. Sleep Deprivation and Disease: Effects on the Body, Brain and Behavior. New York, NY: Springer Science and Business Media; 2015: 101-109
    Google Scholar
  • 11 Coble PA, Reynolds III CF, Kupfer DJ, Houck PR, Day NL, Giles DE. Childbearing in women with and without a history of affective disorder. II. Electroencephalographic sleep. Compr Psychiatry 1994; 35 (03) 215-224
    CrossrefPubMedGoogle Scholar
  • 12 Vgontzas AN, Liao D, Bixler EO, Chrousos GP, Vela-Bueno A. Insomnia with objective short sleep duration is associated with a high risk for hypertension. Sleep 2009; 32 (04) 491-497
    CrossrefPubMedGoogle Scholar
  • 13 Gozal D, Serpero LD, Kheirandish-Gozal L, Capdevila OS, Khalyfa A, Tauman R. Sleep measures and morning plasma TNF-alpha levels in children with sleep-disordered breathing. Sleep 2010; 33 (03) 319-325
    CrossrefPubMedGoogle Scholar
  • 14 Irwin MR, Wang M, Campomayor CO, Collado-Hidalgo A, Cole S. Sleep deprivation and activation of morning levels of cellular and genomic markers of inflammation. Arch Intern Med 2006; 166 (16) 1756-1762
    CrossrefPubMedGoogle Scholar
  • 15 Okun ML, Roberts JM, Marsland AL, Hall M. How disturbed sleep may be a risk factor for adverse pregnancy outcomes. Obstet Gynecol Surv 2009; 64 (04) 273-280
    CrossrefPubMedGoogle Scholar
  • 16 Okun ML, Hall M, Coussons-Read ME. Sleep disturbances increase interleukin-6 production during pregnancy: implications for pregnancy complications. Reprod Sci 2007; 14 (06) 560-567
    CrossrefPubMedGoogle Scholar
  • 17 Lee KA, Gay CL. Sleep in late pregnancy predicts length of labor and type of delivery. Am J Obstet Gynecol 2004; 191 (06) 2041-2046
    CrossrefPubMedGoogle Scholar
  • 18 Williams MA, Miller RS, Qiu C, Cripe SM, Gelaye B, Enquobahrie D. Associations of early pregnancy sleep duration with trimester-specific blood pressures and hypertensive disorders in pregnancy. Sleep 2010; 33 (10) 1363-1371
    CrossrefPubMedGoogle Scholar
  • 19 Qiu C, Enquobahrie D, Frederick IO, Abetew D, Williams MA. Glucose intolerance and gestational diabetes risk in relation to sleep duration and snoring during pregnancy: a pilot study. BMC Womens Health 2010; 10: 17
    CrossrefPubMedGoogle Scholar
  • 20 Facco FL, Grobman WA, Reid KJ. , et al. Objectively measured short sleep duration and later sleep midpoint in pregnancy are associated with a higher risk of gestational diabetes. Am J Obstet Gynecol 2017; 217 (04) 447.e1-447.e13
    CrossrefPubMedGoogle Scholar
  • 21 Dempsey JA, Veasey SC, Morgan BJ, O'Donnell CP. Pathophysiology of sleep apnea. Physiol Rev 2010; 90 (01) 47-112
    CrossrefPubMedGoogle Scholar
  • 22 Somers VK, Dyken ME, Clary MP, Abboud FM. Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest 1995; 96 (04) 1897-1904
    CrossrefPubMedGoogle Scholar
  • 23 Narkiewicz K, Kato M, Phillips BG, Pesek CA, Davison DE, Somers VK. Nocturnal continuous positive airway pressure decreases daytime sympathetic traffic in obstructive sleep apnea. Circulation 1999; 100 (23) 2332-2335
    CrossrefPubMedGoogle Scholar
  • 24 White DP. Pathogenesis of obstructive and central sleep apnea. Am J Respir Crit Care Med 2005; 172 (11) 1363-1370
    CrossrefPubMedGoogle Scholar
  • 25 Owens RL, Edwards BA, Eckert DJ. , et al. An integrative model of physiological traits can be used to predict obstructive sleep apnea and response to non positive airway pressure therapy. Sleep 2015; 38 (06) 961-970
    PubMedGoogle Scholar
  • 26 Shamsuzzaman AS, Gersh BJ, Somers VK. Obstructive sleep apnea: implications for cardiac and vascular disease. JAMA 2003; 290 (14) 1906-1914
    CrossrefPubMedGoogle Scholar
  • 27 Bourjeily G, Fung JY, Sharkey KM. , et al. Airflow limitations in pregnant women suspected of sleep-disordered breathing. Sleep Med 2014; 15 (05) 550-555
    CrossrefPubMedGoogle Scholar
  • 28 O'Connor C, Thornley KS, Hanly PJ. Gender differences in the polysomnographic features of obstructive sleep apnea. Am J Respir Crit Care Med 2000; 161 (05) 1465-1472
    CrossrefPubMedGoogle Scholar
  • 29 Mills GH, Chaffe AG. Sleeping positions adopted by pregnant women of more than 30 weeks gestation. Anaesthesia 1994; 49 (03) 249-250
    PubMedGoogle Scholar
  • 30 Itasaka Y, Miyazaki S, Ishikawa K, Togawa K. The influence of sleep position and obesity on sleep apnea. Psychiatry Clin Neurosci 2000; 54 (03) 340-341
    CrossrefPubMedGoogle Scholar
  • 31 Manber R, Kuo TF, Cataldo N, Colrain IM. The effects of hormone replacement therapy on sleep-disordered breathing in postmenopausal women: a pilot study. Sleep 2003; 26 (02) 163-168
    PubMedGoogle Scholar
  • 32 Popovic RM, White DP. Upper airway muscle activity in normal women: influence of hormonal status. J Appl Physiol (1985) 1998; 84 (03) 1055-1062
    CrossrefPubMedGoogle Scholar
  • 33 Elkus R, Popovich Jr J. Respiratory physiology in pregnancy. Clin Chest Med 1992; 13 (04) 555-565
    CrossrefPubMedGoogle Scholar
  • 34 Gunderson EP, Abrams B. Epidemiology of gestational weight gain and body weight changes after pregnancy. Epidemiol Rev 1999; 21 (02) 261-275
    CrossrefPubMedGoogle Scholar
  • 35 Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA 2000; 284 (23) 3015-3021
    CrossrefPubMedGoogle Scholar
  • 36 Sahota PK, Jain SS, Dhand R. Sleep disorders in pregnancy. Curr Opin Pulm Med 2003; 9 (06) 477-483
    CrossrefPubMedGoogle Scholar
  • 37 Haas DM, Parker CB, Wing DA. , et al; NuMoM2b study. A description of the methods of the Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be (nuMoM2b). Am J Obstet Gynecol 2015; 212 (04) 539.e1-539.e24
    CrossrefPubMedGoogle Scholar
  • 38 Facco FL, Parker CB, Reddy UM. , et al. NuMoM2b Sleep-Disordered Breathing study: objectives and methods. Am J Obstet Gynecol 2015; 212 (04) 542.e1-542.e127
    CrossrefPubMedGoogle Scholar
  • 39 Facco FL, Parker CB, Reddy UM. , et al. Association between sleep-disordered breathing and hypertensive disorders of pregnancy and gestational diabetes mellitus. Obstet Gynecol 2017; 129 (01) 31-41
    CrossrefPubMedGoogle Scholar
  • 40 Facco FL, Ouyang DW, Zee PC, Grobman WA. Sleep disordered breathing in a high-risk cohort prevalence and severity across pregnancy. Am J Perinatol 2014; 31 (10) 899-904
    Article in Thieme ConnectPubMedGoogle Scholar
  • 41 Edwards N, Blyton DM, Hennessy A, Sullivan CE. Severity of sleep-disordered breathing improves following parturition. Sleep 2005; 28 (06) 737-741
    CrossrefPubMedGoogle Scholar
  • 42 Facco FL, Ouyang DW, Zee PC, Grobman WA. Development of a pregnancy-specific screening tool for sleep apnea. J Clin Sleep Med 2012; 8 (04) 389-394
    PubMedGoogle Scholar
  • 43 Ustun B, Westover MB, Rudin C, Bianchi MT. Clinical prediction models for sleep apnea: the importance of medical history over symptoms. J Clin Sleep Med 2016; 12 (02) 161-168
    CrossrefPubMedGoogle Scholar
  • 44 Reid J, Skomro R, Cotton D. , et al. Pregnant women with gestational hypertension may have a high frequency of sleep disordered breathing. Sleep 2011; 34 (08) 1033-1038
    CrossrefPubMedGoogle Scholar
  • 45 O'Brien LM, Bullough AS, Chames MC. , et al. Hypertension, snoring, and obstructive sleep apnoea during pregnancy: a cohort study. BJOG 2014; 121 (13) 1685-1693
    CrossrefPubMedGoogle Scholar
  • 46 Jerath R, Barnes VA, Fadel HE. Mechanism of development of pre-eclampsia linking breathing disorders to endothelial dysfunction. Med Hypotheses 2009; 73 (02) 163-166
    CrossrefPubMedGoogle Scholar
  • 47 Nadeem R, Molnar J, Madbouly EM. , et al. Serum inflammatory markers in obstructive sleep apnea: a meta-analysis. J Clin Sleep Med 2013; 9 (10) 1003-1012
    CrossrefPubMedGoogle Scholar
  • 48 Redman CW, Sargent IL. Pre-eclampsia, the placenta and the maternal systemic inflammatory response--a review. Placenta 2003; 24 (Suppl A): S21-S27
    CrossrefPubMedGoogle Scholar
  • 49 Louis J, Auckley D, Miladinovic B. , et al. Perinatal outcomes associated with obstructive sleep apnea in obese pregnant women. Obstet Gynecol 2012; 120 (05) 1085-1092
    PubMedGoogle Scholar
  • 50 Chen YH, Kang JH, Lin CC, Wang IT, Keller JJ, Lin HC. Obstructive sleep apnea and the risk of adverse pregnancy outcomes. Am J Obstet Gynecol 2012; 206 (02) 136.e1-136.e5
    CrossrefPubMedGoogle Scholar
  • 51 Louis JM, Auckley D, Sokol RJ, Mercer BM. Maternal and neonatal morbidities associated with obstructive sleep apnea complicating pregnancy. Am J Obstet Gynecol 2010; 202 (03) 261.e1-261.e5
    CrossrefPubMedGoogle Scholar
  • 52 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 (01) 9-14
    CrossrefPubMedGoogle Scholar
  • 53 Poyares D, Guilleminault C, Hachul H. , et al. Pre-eclampsia and nasal CPAP: part 2. Hypertension during pregnancy, chronic snoring, and early nasal CPAP intervention. Sleep Med 2007; 9 (01) 15-21
    CrossrefPubMedGoogle Scholar
  • 54 Whitehead C, Tong S, Wilson D, Howard M, Walker SP. Treatment of early-onset preeclampsia with continuous positive airway pressure. Obstet Gynecol 2015; 125 (05) 1106-1109
    CrossrefPubMedGoogle Scholar
  • 55 Edwards N, Blyton DM, Kirjavainen T, Kesby GJ, Sullivan CE. Nasal continuous positive airway pressure reduces sleep-induced blood pressure increments in preeclampsia. Am J Respir Crit Care Med 2000; 162 (01) 252-257
    CrossrefPubMedGoogle Scholar
  • 56 Allen RP, Picchietti D, Hening WA, Trenkwalder C, Walters AS, Montplaisi J. ; Restless Legs Syndrome Diagnosis and Epidemiology workshop at the National Institutes of Health; International Restless Legs Syndrome Study Group. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Med 2003; 4 (02) 101-119
    CrossrefPubMedGoogle Scholar
  • 57 Montplaisir J, Boucher S, Poirier G, Lavigne G, Lapierre O, Lespérance P. Clinical, polysomnographic, and genetic characteristics of restless legs syndrome: a study of 133 patients diagnosed with new standard criteria. Mov Disord 1997; 12 (01) 61-65
    CrossrefPubMedGoogle Scholar
  • 58 Allen R. Dopamine and iron in the pathophysiology of restless legs syndrome (RLS). Sleep Med 2004; 5 (04) 385-391
    CrossrefPubMedGoogle Scholar
  • 59 Sun ER, Chen CA, Ho G, Earley CJ, Allen RP. Iron and the restless legs syndrome. Sleep 1998; 21 (04) 371-377
    PubMedGoogle Scholar
  • 60 Earley CJ, Connor JR, Beard JL, Malecki EA, Epstein DK, Allen RP. Abnormalities in CSF concentrations of ferritin and transferrin in restless legs syndrome. Neurology 2000; 54 (08) 1698-1700
    CrossrefPubMedGoogle Scholar
  • 61 Allen RP, Barker PB, Wehrl FW, Song HK, Earley CJ. MRI measurement of brain iron in patients with restless legs syndrome. Neurology 2001; 56 (02) 263-265
    CrossrefPubMedGoogle Scholar
  • 62 Roux FJ. Restless legs syndrome: impact on sleep-related breathing disorders. Respirology 2013; 18 (02) 238-245
    CrossrefPubMedGoogle Scholar
  • 63 Lakshminarayanan S, Paramasivan KD, Walters AS, Wagner ML, Patel S, Passi V. Clinically significant but unsuspected restless legs syndrome in patients with sleep apnea. Mov Disord 2005; 20 (04) 501-503
    CrossrefPubMedGoogle Scholar
  • 64 Earley CJ, Connor J, Garcia-Borreguero D. , et al. Altered brain iron homeostasis and dopaminergic function in Restless Legs Syndrome (Willis-Ekbom Disease). Sleep Med 2014; 15 (11) 1288-1301
    CrossrefPubMedGoogle Scholar
  • 65 Delgado Rodrigues RN, Alvim de Abreu E Silva Rodrigues AA, Pratesi R, Krieger J. Outcome of restless legs severity after continuous positive air pressure (CPAP) treatment in patients affected by the association of RLS and obstructive sleep apneas. Sleep Med 2006; 7 (03) 235-239
    CrossrefPubMedGoogle Scholar
  • 66 Manconi M, Govoni V, De Vito A. , et al. Pregnancy as a risk factor for restless legs syndrome. Sleep Med 2004; 5 (03) 305-308
    CrossrefPubMedGoogle Scholar
  • 67 Manconi M, Govoni V, De Vito A. , et al. Restless legs syndrome and pregnancy. Neurology 2004; 63 (06) 1065-1069
    CrossrefPubMedGoogle Scholar
  • 68 Cesnik E, Casetta I, Turri M. , et al. Transient RLS during pregnancy is a risk factor for the chronic idiopathic form. Neurology 2010; 75 (23) 2117-2120
    CrossrefPubMedGoogle Scholar
  • 69 Wesström J, Skalkidou A, Manconi M, Fulda S, Sundström-Poromaa I. Pre-pregnancy restless legs syndrome (Willis-Ekbom Disease) is associated with perinatal depression. J Clin Sleep Med 2014; 10 (05) 527-533
    PubMedGoogle Scholar
  • 70 Innes KE, Kandati S, Flack KL, Agarwal P, Selfe TK. The association of restless legs syndrome to history of gestational diabetes in an Appalachian primary care population. J Clin Sleep Med 2015; 11 (10) 1121-1130
    PubMedGoogle Scholar
  • 71 Oyieng'o DO, Kirwa K, Tong I, Martin S, Antonio Rojas-Suarez J, Bourjeily G. Restless legs symptoms and pregnancy and neonatal outcomes. Clin Ther 2016; 38 (02) 256-264
    CrossrefPubMedGoogle Scholar
  • 72 Dunietz GL, Lisabeth LD, Shedden K. , et al. Restless legs syndrome and sleep-wake disturbances in pregnancy. J Clin Sleep Med 2017; 13 (07) 863-870
    PubMedGoogle Scholar
  • 73 Picchietti DL, Hensley JG, Bainbridge JL. , et al; International Restless Legs Syndrome Study Group (IRLSSG). Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis-Ekbom disease during pregnancy and lactation. Sleep Med Rev 2015; 22: 64-77
    CrossrefPubMedGoogle Scholar
  • 74 St Louis EK. Key sleep neurologic disorders: Narcolepsy, restless legs syndrome/Willis-Ekbom disease, and REM sleep behavior disorder. Neurol Clin Pract 2014; 4 (01) 16-25
    CrossrefPubMedGoogle Scholar