Research
www.AJOG.org
OBSTETRICS
Obstructive sleep apnea and the risk
of adverse pregnancy outcomes
Yi-Hua Chen, PhD; Jiunn-Horng Kang, MD; Ching-Chun Lin, MA;
I-Te Wang, MD; Joseph J. Keller, MPH; Herng-Ching Lin, PhD
OBJECTIVE: We examined the risk of adverse pregnancy outcomes, in-
with OSA were 1.76 (95% confidence interval [CI], 1.28 -2.40), 2.31
cluding low birthweight (LBW), preterm birth, small for gestational age
(95% CI, 1.77-3.01), 1.34 (95% CI, 1.09 -1.66), 1.74 (95% CI, 1.48 -
(SGA), cesarean section (CS), low Apgar score (at 5 minutes after deliv-
2.04), and 1.60 (95% CI, 2.16 -11.26), respectively.
ery), and preeclampsia in pregnant women with and without obstructive
sleep apnea (OSA).
CONCLUSION: Pregnant women with OSA are at increased risk for hav-
STUDY DESIGN: Our subjects included 791 women with OSA and
ing LBW, preterm, and SGA infants, CS, and preeclampsia, compared
3955 randomly selected women without OSA. We performed condi-
with pregnant women without OSA.
tional logistic regression analyses to examine the risks of adverse preg-
nancy outcomes between women with and without OSA.
RESULTS: Compared with women without OSA, adjusted odds ratios
Key words: cesarean section, obstructive sleep apnea, pregnancy
for LBW, preterm birth, SGA infants, CS, and preeclampsia in women
outcome
Cite this article as: Chen Y-H, Kang J-H, Lin C-C, et al. Obstructive sleep apnea and the risk of adverse pregnancy outcomes. Am J Obstet Gynecol 2012;206:136.e1-5.
Obstructive sleep apnea (OSA), a self-reports, found that frequent snor- jectsfromWesterncountries.Therefore,
common sleep-related breathing
ing is reported more often in pregnant
whether there was an association be-
disorder, is characterized by recurrent
women than in nonpregnant women.
tween OSA and adverse pregnancy out-
collapse or blockage of the pharynx dur-
However, the incidence of OSA in preg-
comes remains unanswered.
ing sleep that causes intermittent cessa-
nant women is unknown.
Using 2 large-scale, nationwide, pop-
tion of airflow and a hallmark snoring-
Patients with OSA commonly had de-
ulation-based datasets, this study aimed
gasping pattern.1-3 The prevalence of
creased quality of life. In particular, OSA
to examine the risk of adverse pregnancy
OSA among women ranges from 0.3% to
affects sleep quality and duration of
outcomes, including LBW, preterm
5 %.4-8 A study by Loube et al, 9 based on
sleep in pregnant women.10,11 Preg-
birth, SGA, CS, lower Apgar score (at 5
nancy causes anatomic, physiologic, and
minutes after delivery), and preeclamp-
endocrinologic changes, including nar-
sia/eclampsia, between pregnant women
From the Schools of Public Health (Dr
Chen), Health Care Administration (Ms
rowing of the upper respiratory tract,
with and without OSA in Taiwan. The
C.-C. Lin and Dr H.-C. Lin), and Medical
which may increase the risk for OSA or
large dataset available from Taiwan pres-
Laboratory Sciences and Biotechnology (Mr
worsen preexisting sleep apneas.12,13
ents an exceptional opportunity to ex-
Keller), Taipei Medical University, and the
Studies have associated OSA in preg-
amine this issue among Asian women.
Sleep Center (Dr Kang) and the
nant women with low birthweight
Departments of Physical Medicine and
(LBW),14,15 preterm birth,16 small for
MATERIALS AND METHODS
Rehabilitation (Dr Kang) and Obstetrics and
gestational age (SGA),9,17 cesarean sec-
Database
Gynecology (Dr Wang), Taipei Medical
tion (CS),3 lower Apgar scores at
We linked 2 nationwide, population-based
University Hospital, Taipei, Taiwan.
birth,14,18 and preeclampsia.7,12
datasets and used the resulting compila-
Received May 14, 2011; revised July 28, 2011;
On the other hand, an empirical study
accepted Sept. 7, 2011.
tion for our analyses. In March 1995, Tai-
by Loube et al9 reported no association
The authors report no conflict of interest.
wan initiated its National Health Insur-
between mothers with frequent snoring
Reprints: Herng-Ching Lin, PhD, School of
ance (NHI) program to finance health care
Health Care Administration, Taipei Medical
and LBW infants (mean birthweights
for all its citizens. Taiwan's NHI has a
University, 250 Wu-Hsing St., Taipei 110,
were 3534
474 g and 3450
652 g for
unique combination of characteristics:
Taiwan. henry11111@tmu.edu.tw.
women with and without OSA, respec-
universal coverage, a single-payer payment
0002-9378/$36.00
tively). Furthermore, previous studies
system with the government as the sole in-
(c) 2012 Mosby, Inc. All rights reserved.
on OSA and pregnancy outcomes were
surer, unrestricted access to any medical
doi: 10.1016/j.ajog.2011.09.006
limited to case reports7,8,17 and selective
institution of the patient's choice, and a
data or small sample sizes9,15; further-
wide variety of providers including pri-
See Journal Club, page 176
more, all the studies reported on sub-
mary care physicians.
136.e1 American Journal of Obstetrics & Gynecology FEBRUARY 2012

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www.AJOG.org
Obstetrics Research
The Taiwan National Health Insur-
780.57, or 327.23) after receiving poly-
278.0, 278.00, and 278.01]); infant sex
ance Research Dataset (NHIRD) is de-
somnograms during ambulatory care
and parity; and father's age in the regres-
rived from the NHI program and in-
visits within 1 year prior to their index
sion modeling to assess the independent
cludes all the original claims data as well
deliveries.
effect of OSA on the specified pregnancy
as registry files of contracted medical fa-
When a physician suspects that a pa-
outcomes.
cilities, board-certified specialists, other
tient has OSA, the physician may give the
medical service providers, and prescrip-
patient a tentative diagnosis of OSA dur-
Statistical analysis
tions covered by the program for the
ing their first visit to perform the related
We performed all analyses in this study
25.68 million enrollees in Taiwan (the
clinical or laboratory tests to confirm the
using the SAS package (SAS Institute).
coverage rate was greater than 98.5% in
OSA diagnosis and avoid any possible
Pearson 2 tests were used to compare
2007). Therefore, the NHIRD includes
fines for performing unnecessary or in-
differences between women with and
comprehensive information on the med-
appropriate procedures. Therefore, we
without OSA in terms of the characteris-
ical utilization of virtually all the preg-
selected only women who had been
tics of mother, infant, and father identi-
nant women in Taiwan and thus offers
given at least 2 consensus OSA diag-
fied in the above-mentioned text. We
an excellent opportunity to examine the
noses after undergoing polysomno-
also used conditional logistic regression
relationship between OSA and preg-
graphic studies to increase coding
analyses that were conditioned on ma-
nancy outcomes.
reliability and validity from this admin-
ternal age to examine the risk of adverse
The national birth certificate registry is
istrative database.
pregnancy outcomes between women
maintained and publicly released by the
To form the comparison group, we
with and without OSA. A 2-sided P
.05
Taiwanese Ministry of the Interior. Ac-
randomly extracted 3955 women (5
was considered statistically significant
cording to law, all births in Taiwan must
women for every woman with OSA)
for this study.
be registered within 10 days following
matched with the study group in terms
the birth. This dataset contains both in-
of age group ( 20, 20-24, 25-29, 30-34,
RESULTS
fants' and parents' demographic, repro-
and
35 years) using the SAS surveyse-
The mean age of the 4746 sampled
ductive, and socioeconomic characteris-
lect procedure (SAS System for Win-
women was 30.3
4.4 years (SD; range,
tics and infants' birth characteristics,
dows, version 8.2; SAS Institute Inc,
14 - 45 years). The mean birthweight for
including birthweight, gestational age,
Cary, NC). We also assured that selected
women with OSA and women without
birth order, and sex. A previous study
women in the comparison group had
OSA were 3063
584 g (SD; range, 361-
has verified the completeness and
never received a diagnosis of OSA since
4650 g) and 3147
418 g (SD; range,
showed high levels of validity in Taiwan's
the initiation of the NHI program in
1426 - 4760 g), respectively. Moreover,
birth registry.19
1995.
the mean gestational age for women with
These 2 nationwide, population-based
OSA and women without OSA were
datasets were linked with assistance from
Variables of interest
38
2.28 weeks (SD; range, 24 - 41
the Bureau of Health Promotion, De-
The independent variable for this study
weeks) and 38
1.45 weeks (SD; range,
partment of Health, Taiwan. Because the
was whether each woman was diagnosed
29 - 43 weeks), respectively.
NHIRD consists of deidentified second-
with OSA within 1 year prior to her index
Table 1 reports the distribution of
ary data released to the public for re-
delivery. The outcome variables selected
characteristics of mothers, infants, and
search purposes, this study was granted
for this study were all dichotomous.
fathers across the study and comparison
approval via summary review by the in-
They included LBW ( 2500 g); preterm
groups. After matching for maternal age,
stitutional review board.
gestation ( 37 completed weeks of ges-
we found no significant differences be-
tation); SGA babies (SGA has been de-
tween women with and without OSA in
Study sample
fined as a birthweight of less than the
infant sex (P
.216), maternal educa-
This cross-sectional design includes a
10th percentile for gestational age by
tion level (P
.156), anemia (P
.989),
study group and a comparison group. To
Lubchenco et al19 and Battaglia and Lub-
and hyperlipidemia (P
.998). How-
form the study group, we first identified
chenco20 in the 1960s); Apgar score at 5
ever, there were significant differences in
218,776 women in Taiwan who had live
minutes less than 7; CS; preeclampsia
infant parity (P
.001), maternal mari-
singleton births between Jan. 1, 2005,
(eclampsia); gestational diabetes; and
tal status (P
.001), coronary heart dis-
and Dec. 31, 2005. If the selected women
gestational hypertension.
ease (P
.001), obesity (P
.001), geo-
had more than 1 singleton birth during
We also adjusted for several mater-
graphic region (P
.001), and paternal
the study period, we included only the
nal characteristics (highest educational
age (P
.003) between women with and
first in the study sample and designated
level, marital status, geographic region,
without OSA.
it an index delivery. Of the 218,776
coronary heart disease [ICD-9-CM
Table 2 presents the prevalence of
women, 791 had been diagnosed with
codes 410-414 or 429.2], anemia [ICD-
LBW, preterm birth, SGA infants, and
OSA (International Classification of Dis-
9-CM codes 280-285], hyperlipidemia
CS by group. Women with OSA had
eases, Ninth Revision, Clinical Modifica-
[ICD-9-CM codes 272 and 272.0-272.9],
higher prevalences of LBW infants (8.6%
tion [ICD-9-CM] codes 780.51, 780.53,
and obesity [ICD-9-CM codes 278,
vs 4.2%, P
.001), preterm birth (12.1%
FEBRUARY 2012 American Journal of Obstetrics & Gynecology
136.e2

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Research Obstetrics
www.AJOG.org
vs 5.4%, P
.001), SGA infants (18.3%
vs 13.5%, P
.001), CS (50.4% vs
TABLE 1
Sociodemographic characteristics of pregnant women with and
37.3%, P
.001), Apgar score at 5 min-
without obstructive sleep apnea in Taiwan, 2005 (n
4746)
utes less than 7 (1.3% vs 0.1%, P
.001),
preeclampsia (1.4% vs. 0.5%, P
.002),
Women with
Women in the
and gestational hypertension (6.7% vs
obstructive
comparison
2.2%, P
.001) than women without
sleep apnea
group
(n
791)
(n
3955)
OSA.
Conditional logistic regression analy-
Variable
n
%
n
%
P value
ses (conditioned on maternal age group)
Infant characteristics
revealed that the odds ratios (ORs) for
.....................................................................................................................................................................................................................................
Sex
.216
LBW, preterm birth, SGA infants, CS,
............................................................................................................................................................................................................................
Apgar score at 5 minutes less than 7, pre-
Male
415
52.5
2170
54.9
............................................................................................................................................................................................................................
eclampsia, gestational diabetes, and ges-
Female
376
47.5
1785
45.1
.....................................................................................................................................................................................................................................
tational hypertension in women with
Parity
.001
OSA were 2.16 (95% confidence inter-
............................................................................................................................................................................................................................
1
364
46.0
1885
47.7
val [CI], 1.61-2.90), 2.40 (95% CI,
............................................................................................................................................................................................................................
1.86 -3.10), 1.44 (95% CI, 1.17-1.76),
2
274
34.6
1575
39.8
............................................................................................................................................................................................................................
1.73 (95% CI, 1.48 -2.02), 10.11 (95%
3
153
19.3
495
12.5
..............................................................................................................................................................................................................................................
CI, 3.45-29.67), 3.08 (95% CI, 1.45-
Maternal characteristics
6.55), 1.45 (95% CI, 0.99 -2.11), and
.....................................................................................................................................................................................................................................
Age, y
1.000
3.32 (95% CI, 2.32- 4.74), respectively,
............................................................................................................................................................................................................................
compared with women without OSA
20
5
0.6
25
0.6
............................................................................................................................................................................................................................
(Table 2).
20-24
68
8.6
340
8.6
............................................................................................................................................................................................................................
Table 2 also presents the adjusted ORs
25-29
263
33.3
1315
33.3
of adverse pregnancy outcome by group
............................................................................................................................................................................................................................
30-34
329
41.6
1645
41.6
after adjusting for maternal highest edu-
............................................................................................................................................................................................................................
cational level, marital status, geographic
34
126
15.9
630
15.9
.....................................................................................................................................................................................................................................
region, gestational diabetes, gestational
Marital status
............................................................................................................................................................................................................................
hypertension, coronary heart disease,
Married
680
86.0
3690
93.3
.001
anemia, hyperlipidemia, obesity, infant
.....................................................................................................................................................................................................................................
Education level
.156
sex and parity, and paternal age. As com-
............................................................................................................................................................................................................................
pared with women without OSA, the ad-
Junior high school or lower
84
10.6
325
8.2
............................................................................................................................................................................................................................
justed ORs in women with OSA for
Senior high school
516
65.2
2670
67.5
............................................................................................................................................................................................................................
LBW, preterm birth, SGA infants, CS,
College or above
191
24.2
960
24.3
and preeclampsia were 1.76 (95% CI,
.....................................................................................................................................................................................................................................
Anemia
60
7.3
290
7.3
.989
1.28 -2.40), 2.31 (95% CI, 1.77-3.01),
.....................................................................................................................................................................................................................................
1.34 (95% CI, 1.09 -1.66), 1.74 (95% CI,
Coronary heart disease
20
2.5
20
0.5
.001
.....................................................................................................................................................................................................................................
1.48 -2.04), and 1.60 (95% CI, 2.16 -
Hyperlipidemia
19
2.4
95
2.4
.998
.....................................................................................................................................................................................................................................
11.26), respectively.
Obesity
17
2.1
60
1.5
.001
Furthermore, we found that mothers
.....................................................................................................................................................................................................................................
Geographic region
.001
with OSA were 1.63 and 3.18 times more
............................................................................................................................................................................................................................
likely than unaffected mothers to have
North
511
64.6
2190
55.4
............................................................................................................................................................................................................................
gestational hypertension and gestational
Center
190
24.0
965
24.4
............................................................................................................................................................................................................................
diabetes, respectively, after adjusting for
South
80
10.1
695
17.6
other confounders. The adjusted ORs for
............................................................................................................................................................................................................................
East
10
1.3
105
2.7
lower Apgar score at 5 minutes was not
..............................................................................................................................................................................................................................................
presented because of the small number
Paternal age, y
.003
.....................................................................................................................................................................................................................................
of cases in which Apgar score at 5 min-
30
291
36.8
1330
33.6
.....................................................................................................................................................................................................................................
utes was less than 7.
30-34
251
31.7
1510
38.2
.....................................................................................................................................................................................................................................
34
249
31.5
1115
28.2
..............................................................................................................................................................................................................................................
C
Chen. Obstructive sleep apnea and pregnancy. Am J Obstet Gynecol 2012.
OMMENT
After adjusting for mother and infant
characteristics, we found that mothers
with OSA were 1.76, 2.31, 1.34, 1.74,
136.e3 American Journal of Obstetrics & Gynecology FEBRUARY 2012

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www.AJOG.org
Obstetrics Research
but experienced preeclampsia and other
TABLE 2
medical problems during the pregnancy.
Distribution and ORs of pregnancy outcomes across
Another case report by Roush and Bell17
study and control groups, 2005 (n
4746)
described a 25 year old woman with OSA
Women in the
who was treated for preeclampsia and
Women with
comparison
delivered an SGA infant.
obstructive sleep
group
In addition, prior studies have re-
apnea (n
791)
(n
3955)
ported that pregnant women with OSA
Variable
n
%
n
%
P value
delivered babies with Apgar scores
LBW
68
8.6
165
4.2
.001
at birth lower than the comparison
.....................................................................................................................................................................................................................................
group.9,14,21 We did not calculate the ad-
OR (95% CI)a
2.16 (1.61-2.90)b
1.00
.....................................................................................................................................................................................................................................
justed ORs for this outcome because
Adjusted OR (95% CI)c
1.76 (1.28-2.40)d
1.00
..............................................................................................................................................................................................................................................
only 10 of the 791 women with OSA in
Preterm birth
96
12.1
215
5.4
.001
.....................................................................................................................................................................................................................................
our sample had Apgar score at 5 minutes
OR (95% CI)a
2.40 (1.86-3.10)b
1.00
.....................................................................................................................................................................................................................................
of less than 7. However, consistent with
Adjusted OR (95% CI)c
2.31 (1.77-3.01)d
1.00
..............................................................................................................................................................................................................................................
prior observations, we found that the
SGA
145
18.3
535
13.5
.001
.....................................................................................................................................................................................................................................
crude OR of low Apgar score at 5 min-
OR (95% CI)a
1.44 (1.17-1.76)b
1.00
.....................................................................................................................................................................................................................................
utes for infants of women with OSA was
Adjusted OR (95% CI)c
1.34 (1.09-1.66)e
1.00
..............................................................................................................................................................................................................................................
10.11 times higher than for infants of
CS
399
50.4
1475
37.3
.001
women without OSA.
.....................................................................................................................................................................................................................................
OR (95% CI)a
1.73 (1.48-2.02)b
1.00
The mechanisms underlying the rela-
.....................................................................................................................................................................................................................................
Adjusted OR (95% CI)c
1.74 (1.48-2.04)d
1.00
tionship between OSA and adverse preg-
..............................................................................................................................................................................................................................................
Low Apgar score at 5 min
10
1.3
5
0.1
.001
nancy outcomes remain obscure. It has
.....................................................................................................................................................................................................................................
been suggested that the frequency and in-
OR (95% CI)a
10.11 (3.45-29.67)d
1.00
.....................................................................................................................................................................................................................................
tensity of OSA-associated apnea and hy-
Adjusted OR (95% CI)c
--
1.00
..............................................................................................................................................................................................................................................
popnea may be low enough to spare moth-
Preeclampsia/eclampsia
11
1.4
18
0.5
.002
.....................................................................................................................................................................................................................................
ers of adverse effects yet still be harmful to
OR (95% CI)a
3.08 (1.45-6.55)e
1.00
.....................................................................................................................................................................................................................................
their more oxygen-sensitive fetuses.7,12
Adjusted OR (95% CI)c
1.60 (2.16-11.26)d
1.00
..............................................................................................................................................................................................................................................
One study by Kambam et al22 reported
Gestational diabetes
37
4.7
130
3.3
.053
.....................................................................................................................................................................................................................................
that greater resistance to airflow had a sig-
OR (95% CI)a
1.45 (0.99-2.11)
1.00
.....................................................................................................................................................................................................................................
nificantly greater impact on the overall ox-
Adjusted OR (95% CI)f
1.63 (1.07-2.48)b
1.00
..............................................................................................................................................................................................................................................
ygen homeostasis in pregnant women than
Gestational hypertension
53
6.7
85
2.2
.001
in nonpregnant women. Another study by
.....................................................................................................................................................................................................................................
OR (95% CI)a
3.32 (2.33-4.74)d
1.00
Loube et al9 also found that the conse-
.....................................................................................................................................................................................................................................
Adjusted OR (95% CI)g
3.18 (2.14-4.73)d
1.00
quences of increased upper airway resis-
..............................................................................................................................................................................................................................................
tance during pregnant women's sleep
CI, confidence interval; CS, cesarean section; LBW, low birthweight; OR, odds ratio; SGA, small size for gestational age.
a Calculated by conditional logistic regression (conditioned on maternal age group); b P
.05; c Adjustments made for mother's
might negatively affect their infants. Fur-
education, marital status, gestational diabetes, gestational hypertension, anemia, coronary heart disease, hyperlipidemia,
ther studies are still needed to characterize
obesity, geographic region, paternal age, infant's sex, and parity; d P
.001; e P
.01; f Adjustments made for mother's
education, marital status, gestational hypertension, anemia, coronary heart disease, hyperlipidemia, obesity, geographic region,
the contributions of biochemical, meta-
paternal age, infant's sex, and parity; g Adjustments made for mother's education, marital status, gestational diabetes, anemia,
bolic, and immune changes arising from
coronary heart disease, hyperlipidemia, obesity, geographic region, paternal age, infant's sex, and parity.
OSA to pregnancy outcome.
Chen. Obstructive sleep apnea and pregnancy. Am J Obstet Gynecol 2012.
Our large datasets, examined for in-
tegrity and validity as described in previ-
1.60, 1.63, and 3.18 times more likely
term deliveries and 6 had preeclampsia.
ous text, provided sufficient statistical
than unaffected mothers to have LBW,
Another study by Louis et al3 also found
power to detect differences and mini-
preterm, SGA babies, CS, preeclampsia,
that women with OSA were more likely
mized probabilities for selection and
gestational diabetes, and gestational hy-
to have preterm births than obese con-
nonresponse biases. Furthermore, more
pertension, respectively.
trols and normal-weight controls (30%
than 98% of Taiwanese inhabitants are
Our findings parallel the conclusions
vs 10% and 12%, respectively; P
.01).
of Han Chinese ethnicity. Although this
of many prior studies.3,7,9,12,14-17 For ex-
A survey study by Loube et al9 showed
limits generalizability to other ethnic
ample, Sahin et al15 reported that fetuses
that SGA occurred in 7.1% of mothers
groups, its homogeneity in this respect
of women with OSA had lower mean
with frequent snoring, compared with
also reduces the probability of ethnic/ge-
birthweights than those of women with-
2.6% of mothers without frequent snor-
netic confounding effects.
out OSA in Turkey. Kapsimalis and Kry-
ing. In a case report, Sagheer et al7 de-
Despite the strengths of our study, the
ger16 found that of 9 pregnant women
scribed a 26 year old pregnant woman
findings should be interpreted in the
with OSA in the United States, 3 had pre-
with OSA, who delivered a healthy baby
context of some limitations. First, previ-
FEBRUARY 2012 American Journal of Obstetrics & Gynecology
136.e4

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Research Obstetrics
www.AJOG.org
ous studies have suggested that obesity
ternal and infant health in Taiwan, poli-
11. Mindell JA, Jacobson BJ. Sleep distur-
may be a major risk factor for the de-
cymakers cannot rely solely on the
bances during pregnancy. J Obstet Gynecol
velopment of OSA.23,24 However, al-
current practice of offering 10 free pre-
Neonatal Nurs 2000;29:590-7.
12. Venkata C, Venkateshiah SB. Sleep-disor-
though we have taken obesity into con-
natal care visits to medical institutions
dered breathing during pregnancy. J Am Board
sideration in the regression model, our
contracted under the NHI program.
Fam Med 2009;22:158-68.
datasets did not contain data on body
Health authorities should promote
13. Pien GW, Schwab RJ. Sleep disorders dur-
mass index. This may have compro-
screening to recognize OSA in pregnant
ing pregnancy. Sleep 2004;27:1405-17.
mised our findings.
women and provide such women with
14. Champagne KA, Kimoff RJ, Barriga PC,
Second, the NHIRD lacks information
heightened levels of health care.
Schwartzman K. Sleep disordered breathing in
women of childbearing age and during preg-
on the severity of OSA, such as apnea-
CPAP, a treatment for upper airway
nancy. Indian J Med Res 2010;131:285-301.
hypopnoea index (AHI) scores or respi-
narrowing during sleep, appears to rep-
15. Sahin FK, Koken G, Cosar E, et al. Obstruc-
ratory disturbance index scores. There-
resent a safe treatment with minimal ad-
tive sleep apnea in pregnancy and fetal out-
fore, we could not test for relationships
verse effects. Moreover, we expect that
come. Int J Gynaecol Obstet 2008;100:141-6.
between severity of OSA and adverse
increased monitoring of mothers with
16. Kapsimalis F, Kryger M. Sleep breathing
pregnancy outcomes.
OSA in gestation would decrease the risk
disorders in the U.S. female population. J
Womens Health (Larchmt) 2009;18:1211-9.
Third, because the NHI database in-
of adverse pregnancy outcomes.
f
17. Roush SF, Bell L. Obstructive sleep apnea
cluded only patients who sought treat-
in pregnancy. J Am Board Fam Pract 2004;
ment, it is possible that some women
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136.e5 American Journal of Obstetrics & Gynecology FEBRUARY 2012

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