Pregnancy and Sleep Disorders:

Pregnancy and Sleep Disorders:

This section is primarily extracted from an article by Grace W. Pien, MD and Richard J.
Schwab, MD. Their article was a review of the existing English publications that looked
at various aspects of sleep and pregnancy. The citation is: Pien GW; Schwab RJ. Sleep
disorders during pregnancy. SLEEP 2004;27(7):1405-17.

During pregnancy the majority of women experience changes in their sleep. Sleepiness is
a common first-trimester complaint. Late in the second trimester, there is a drop in total
sleep time and an increase in sleep complaints. During the third trimester, almost all
women report altered sleep.

What causes some of these changes?

Hormone changes:
Starting
almost
from
conception, women experience changes in their
hormones. Both Progesterone and Estrogen increase throughout the pregnancy and
rapidly return to normal levels after delivery. How do these hormones affect sleep?


Progesterone: Decreases the amount of dream sleep a person has and
increases the non-dream portion of sleep. It can decrease the amount of time between
getting into bed and falling asleep.


Estrogen: This also decreases the amount of dream sleep.

General discomfort:


Back ache, urinary frequency, spontaneous awakening, fetal movement,
heartburn, leg discomfort, difficulty falling asleep or staying asleep

Following delivery the greatest problem with sleep occurs in the first month due to
demands the baby places on the primary care taker. One study showed that women who
nurse their children have get more than twice as much restorative slow wave sleep than
mothers who bottle feed their babies.

Obstructive Sleep Apnea and pregnancy.

It is possible that pregnant women can develop sleep apnea during pregnancy. In studies
of non-pregnant populations, a 20 % weight gain has a very significant impact on the
development of OSA. Since pregnant women often have similar weight gains it is
theoretically possible that many will develop breathing problems that can affect the
developing fetus.

Snoring is the lowest level of sleep disordered breathing. Only 4% of healthy young
women snore; the fact that reports of snoring increase to 25% of pregnant women by the
third trimester, points to other possible negative side-effects of compromised breathing.
The more overweight a woman is before she gets pregnant, the more likely there will be
alterations in her breathing at night. Studies of pregnant women show that snorers have
higher blood pressure than non-snorers.

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Sleep apnea is known to increase blood pressure in patients, in the beginning this is seen
only during sleep and could be missed at a medical appointment. There is a pregnancy-
induced hypertension that can develop after the 20th week of pregnancy and can cause
many problems with the developing baby and the mother’s health. When this gets out of
control, it is called preeclampsia or, worse yet, eclampsia and can be fatal. Known risk
factors for preeclampsia include family history, advancing maternal age, obesity, chronic
hypertension and kidney disease.

As of now, no one knows if sleep apnea, and the intermittent lack of oxygen it causes at
night, causes the blood vessel breakdown in the placenta seen with preeclampsia or if the
retention of fluid from the preeclampsia causes the breathing problems due to tissue
swelling all over the mother’s body. Obstetricians are always on the lookout for this
condition and will treat it aggressively.

Treatment of Sleep Apnea during pregnancy:

Who should be treated?


Any woman who is diagnosed with severe sleep apnea or who has drops in
her blood oxygen level below 90% must be treated as quickly as possible. If the mother is
not breathing properly at night, the fetus can suffer growth retardation which impacts the
baby’s survival after delivery.

How should she be treated?


CPAP (Continuous Positive Air Pressure)



There is no other option that will be as helpful for the fetus. It is
not sexy, or comfortable, but it is only required during the remainder of the pregnancy
and will help protect the baby.


Oral appliances, though effective, require time to fabricate and up to
three months to be maximally effective. By the time effective oral appliance therapy is
instituted, the pregnancy will be over. All oral appliances accepted by the FDA are
custom fabricated and must be obtained from a dentist trained in the fabrication of these
appliances; this makes them too expensive and under-effective for use during pregnancy.
Even women who were diagnosed with sleep apnea prior to pregnancy and have been
using an oral appliance effectively, a return to CPAP use during pregnancy is highly
recommended. One of the many changes taking place in the pregnant woman’s body is a
‘relaxation’ of joints to allow passage of the baby through the birth canal; oral appliances
put significant pressure on the jaw joint at night, and the natural ‘relaxation of joints’
during pregnancy can rapidly lead to permanent changes in the position of the woman’s
jaw.


Surgery: is less effective than any other therapy for sleep apnea and not
an approach to be taken during pregnancy unless there is

What to do after delivery?

Women who develop sleep apnea during pregnancy should have a follow-up sleep
study after regaining her normal weight (2-3 months after delivery) This will verify if the
sleep apnea has resolved. Some women take longer to shed the extra weight of pregnancy
and may continue to have sleep apnea. Since sleep apnea makes people feel sleepy, and a
new baby also disrupts a mother’s sleep, treatment is necessary to keep the new mother

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from experiencing severe sleep deprivation. Some researchers have wondered if this loss
of sleep may be part of the cause of “post-partum depression”.

All women who have developed sleep apnea during a pregnancy must be monitored with
each subsequent pregnancy to determine if the sleep apnea has gotten worse.

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