Pregnancy

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In a study presented on today at the Society for Maternal-Fetal Medicine’s annual meeting, The Pregnancy Meeting, in San Francisco, researchers reported findings that women with obstructive sleep apnea (OSA) and cardiac symptoms have a 31 percent incidence of cardiac dysfunction. The use of echocardiograms should be considered in the clinical management of these women.

OSA is characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. These pauses can last from at least ten seconds to minutes, and may occur five to 30 times or more an hour; this can lead to cardiovascular disease. The objective of the trial was to measure the incidence of OSA among pregnant and reproductive women.

The cohort was made up of 1,265 women between the ages of 15-45 who met the Apnea-Hypopnea Index (AHI) criteria for OSA based on nocturnal Polysomnogram testing. Data was gathered from 2005-2012 at a tertiary care center. Sleep lab data and individual transthoracic echocardiogram reports were reviewed.

“As obesity rates increase among reproductive age women, the frequency of obstructive sleep apnea and cardiovascular disease in pregnancy is anticipated to rise. The increased hemodynamic demands of pregnancy can cause women with underlying cardiac disease to decompensate,” said Laura K.P. Vricella, MD, fellow, Maternal-Fetal Medicine at MetroHealth Medical Center.

“We found a 31 percent incidence of abnormal echocardiograms among symptomatic women with obstructive sleep apnea. Further investigation is needed to understand the relationship between obstructive sleep apnea and cardiovascular disease and their impact on pregnant women.”

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Read the newsletter: Snore Centre eNewsletter Jan 2013

 

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A new study suggests that treatment of mild sleep-disordered breathing with continuous positive airway pressure (CPAP) therapy in pregnant women with preeclampsia improves fetal activity levels, a marker of fetal well-being.

Results show that the average number of fetal movements increased from 319 during a night without CPAP treatment to 592 during the subsequent night with CPAP therapy. During the course of the night without CPAP treatment, the number of fetal movements decreased steadily by 7.4 movements per hour. In contrast, the number of fetal movements increased by 12.6 per hour during the night with CPAP therapy.

“What would otherwise have been considered clinically unimportant or minor ‘snoring’ likely has major effects on the blood supply to the fetus, and that fetus in turn protects itself by reducing movements,” said Colin Sullivan, PhD, the study’s principal investigator. “This can be treated with readily available positive airway pressure therapy and suggests that measurement of fetal activity during a mother’s sleep may be an important and practical method of assessing fetal well-being.”

The three-part study, appearing in the January issue of the journal SLEEP, began with the validation of a fetal activity monitor against ultrasound in 20 normal, third-trimester pregnant women. The next phase of the study measured fetal movement overnight in 20 women with moderate to severe preeclampsia and 20 matched control subjects. Results show that the number of fetal movements during maternal sleep was significantly lower in the preeclampsia group (289) than the control group (689).

In the final phase of the study, fetal movement was measured on consecutive nights in 10 women with moderate to severe preeclampsia, the first night without treatment and the second night with nasal CPAP therapy. The women had mild sleep-disordered breathing with an apnea/hypopnea index of 7.0 breathing pauses per hour of sleep. A minimal mean CPAP pressure of 7 cm H2O was needed to eliminate upper airway obstruction and airflow limitation.

“Maternal SDB represents a unique opportunity to study the effect of in utero exposures on postnatal development and future risk. This has major implications for public health,” Louise M. O’Brien, PhD, MS, associate professor at the University of Michigan, wrote in a commentary on the study. “It raises the possibility that a simple, noninvasive therapy for SDB may improve fetal well-being.”

According to the authors, preeclampsia affects about five percent of pregnancies and is dangerous for the mother as well as a risk factor for fetal growth restriction. It involves the onset of high blood pressure and protein in the urine after the 20th week of pregnancy.

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The Daily Mail reports today that women who suffer from sleep apnoea during pregnancy are more likely to have babies who suffer from early health problems according to researchers.

They found babies of mothers with the breathing disorder had a greater risk of needing neonatal intensive care than unaffected mothers. Scientists from Case Western Reserve University in Cleveland studied obese pregnant women both with and without obstructive sleep apnoea. They found OSA was also associated with higher rates of pre-eclampsia in the overweight women.

The pregnancy complication causes high blood pressure and for protein to leak into the urine. If untreated it can develop into eclampsia, which is a type of life-threatening seizure. Lead author Dr Judette Louis, from the University of South Florida, said: “Our findings show that obstructive sleep apnea can contribute to poor outcomes for both obese mothers and their babies. Its role as a risk factor for adverse pregnancy outcomes independent of obesity should be examined more closely.”

Dr Louis and former colleagues from Case Western Reserve, analysed data for 175 obese pregnant women who had been tested for OSA at home using a portable device. Around 15 per cent of the participants had sleep apnoea. These women were heavier on average and more likely to have high blood pressure.

Around 42 per cent of women with sleep apnoea had pre-eclampsia compared to 17 per cent of those without the condition. Meanwhile nearly half (46 per cent ) of babies born to women with sleep apnoea needed intensive care treatment compared to 17 per cent of the other overweight mothers. Many of these admissions were due to respiratory distress.

Finally, 65 per cent of the women with sleep apnoea required a caesaeran section compared to a third of those without the condition. Premature birth rates were similar between the groups. Approximately one in five women are obese when they become pregnant in the U.S,  according to research from the federal Centers for Disease Control and Prevention. There are no stats available for the UK.

The study has been published online in the journal Obstetrics & Gynecology.

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It is possible that pregnant women can develop sleep apnoea 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.

Sleep apnoea 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 apnoea, 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 Apnoea during pregnancy:

Who should be treated?

Any woman who is diagnosed with severe sleep apnoea 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.

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

What to do after delivery?

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

Source: Pien GW; Schwab RJ. Sleep disorders during pregnancy. SLEEP 2004;27(7):1405-17.

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This is an article I have written for You and Your family, who send out the baby book to all expectant mothers:

Pregnancy and then a new baby can make getting enough sleep difficult, especially if your partner suffers from Sleep Apnoea…

When your baby arrives you will want to be on top form in order to give him or her all the care and attention they need, day or night. The chances are that you will also be among the three quarters of women who have difficulty getting enough sleep during pregnancy.

Leg cramps, heartburn, frequent toilet trips, can all make sleep difficult. So when you have the opportunity for sleep you need to make the most of it. Good practices to avoid insomnia include taking daily exercise, not smoking or drinking alcohol, avoiding caffeine in the evenings, and not eating a big meal too close to bedtime.

However, it could be your partner that is giving you sleepless nights if he has a snoring problem; and it could be due to a medical condition. The most common sleep disorder is called Obstructive Sleep Apnoea, and men are twice as likely to suffer from this than women.

The problem itself is a disrupted breathing pattern during sleep caused by a closing of the upper airways of the lungs when you relax and a period of time when your body stops breathing. Common indicators of Sleep Apnoea are loud snoring, daytime fatigue, memory loss, frequent urination, and loss of interest in sex.

Sleep Apnoea also carries significant health risks, increasing the risk of high blood pressure, heart attack, stroke, type 2 diabetes, and obesity.

Sleep Apnoea can usually be treated by making small lifestyle changes, but moderate or severe Sleep Apnoea may require wearing a CPAP machine while you sleep. This is a mask attached to a machine that helps you to breathe at night by providing a steady supply of air.

If you are concerned that you or your partner may be suffering from Sleep Apnoea it is advisable to consult your GP, who can then refer you to specialist for diagnosis and treatment.

When your new baby arrives you will need all the rest you can get, so it makes sense to get a sleeping disorder treated in plenty of time for the birth.


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