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Perinatal outcomes associated with sleep abnormalities in Pregnancy
Professor Sailesh Kumar
Mater Centre for Maternal & Fetal Medicine
Mater Research Institute – University of Queensland
Head, Academic Discipline of Obstetrics & Gynaecology
University of Queensland
Sleep
• A complex behavioral function
• Conserved across species
• Active process
• Deprivation and disruption results in functional,
cognitive and neuroendocrine impairments
Sleep disordered breathing (SDB)
• A spectrum of increasing severity ranging from snoring to obstructive sleep apnea.
• Associated with repeated partial or complete upper airway obstruction during sleep that resolves with arousal, but results in poor sleep and episodic hypoxemia and hypercarbia.
SnoringObstructive sleep apnea (OSA)
Sleep disordered breathing and pregnancy
• Occurs in 10-32% of pregnancies
• 15-20% of obese pregnant women have OSA
• 30% of pregnant women snore in the 3rd trimester
• Prevalence is probably underestimated and is likely rising
• Pregnancy can precipitate or worsen SDB
• Frequently underdiagnosed because of lack of validated screening tools and insufficient awareness
• Possibly 2 different phenotypes – Pre-existing SDB with worsening in pregnancy (Chronic OSA) and women that develop SDB due to weight gain and airway/respiratory changes of pregnancy (Gestational OSA)
BMI data
10
10.5
11
11.5
12
12.5
13
13.5
14
2001200220032004200520062007200820092010201120122013201420152016
Percentage of women with BMI >30 at
MMH by year
BMI >30
500
700
900
1100
1300
1500
Number of women
Number of women
Pregnancy
“magnified stress test to the respiratory system”
Outside of pregnancy
• Upper airway narrowing
• Reduced lung volume
During pregnancy
• Hormonal/physiological changes
• Narrowing of the upper airways secondary to mucosal edema and vascular congestion
• Decreased lung volume and functionalresidual capacity
• Increased oxygen consumption
Possible mechanisms of action
How & when to screen women for SDB in pregnancy
HST may underestimate severity of OSA but likely to detect moderate to severe cases
AJOG May 2018
3705 Nulliparous women
Home portable sleep monitors used
AHI >5 used to define SDB
A model incorporating maternal age, BMI and
frequency of snoring achieved good prediction for
SDB in early pregnancy, SDB in mid-pregnancy and
new-onset SDB in mid-pregnancy.
AUROC Curve >0.80
Screening extremely obese pregnant women for obstructive sleep apneaDominguez et al, AJOG September 2018
Key findings:
Current screening tests (ASA checklist, Berlin Questionnaire or Epworth SS, STOP-BANG) perform very poorly to screen for OSA
Age, BMI, neck circumference (>35.5cm), frequent witnessed apneas and likely to fall asleep while driving most strongly associated with OSA
Further studies needed to establish criteria and thresholds to better predict OSA in women with extreme obesity
OSA associated with increased odds of pregnancy-related morbidities
55,781,965 pregnancy-related inpatient hospital discharges
1. Pre-eclampsia (OR, 2.5; 95% CI, 2.2–2.9)
2. Eclampsia (OR, 5.4; 95% CI, 3.3–8.9)
3. Cardiomyopathy (OR, 9.0; 95% CI, 7.5–10.9)
4. Pulmonary embolism (OR, 4.5; 95% CI, 2.3–8.9).
5. 5X increased odds of in-hospital mortality (95% CI, 2.4–11.5).
6. Adverse outcomes exacerbated by obesity. Sleep 2014
• Data from National Perinatal Information Centre
• 1,577,632 deliveries
• Coded for OSA – 0.12% of women
• Women with OSA – Older, Black ethnicity, higher BMI, Smokers, MultiplePregnancy, Drug Use
Maternal and Fetal Outcomes
AJOG 2018
Maternal demographics
A: Age (OR 1.66)
B: BMI (OR 3.31)
Obstetric Outcomes
A: Gestational age at birth
B: Preterm Birth (OR 1.86)
C: Birthweight
D/E: Low birthweight (<10th centile or <2.5kg) (OR 1.67)
F: Maternal wound complications (OR 3.67)
Intrapartum outcomes
A: Vaginal birth (OR 0.61)
B: Assisted vaginal delivery (OR 1.88)
C: Overall CS birth (OR 1.81)
D: Elective CS birth (OR 1.38)
E: Emergency CS birth (OR 2.52)
F: Meconium stained liquor
Perinatal outcomes
A: Low Apgar Score <7 (OR 2.14)
B: Stillbirth/perinatal death (OR 2.02)
C: NICU/SCN admission (OR 1.90)
D: Cord pH
SDB, Sleep quality, Sleep duration, Supine sleep position
Adverse impact on:
• Birthweight
• Fetal growth
• Preterm birth
• Stillbirth
Sleep position? Relationship between sleep position and adverse perinatal outcomes including SB
Maternal haemodynamics are influenced by maternal posture – in particular, a supine position can reduce uterine perfusion
Supine sleep position
• 6 case-control studies with 851 SB cases and 2257 controls
• Supine going-to-sleep position had increased odds of late (>28weeks) SBadjusted odds ratio [aOR] 2.63, 95% CI 1.72–4.04, p<0.0001
• Going-to-sleep on left or right side appears equally safe.
Triple risk model
Maternal factors in the setting of a vulnerable fetus combined with a stressor, such as supine sleep position or SDB, could have the catastrophic outcome of stillbirth or other adverse pregnancy outcomes.
Any of these factors individually may be insufficient to cause a stillbirth/adverse perinatal outcomes, however when they occur simultaneously, they have grave consequences.
Conclusions• SDB associated with several maternal and fetal complications
• Maternal: Hypertensive disorders, gestational diabetes mellitus, cardiomyopathy, ICU admission, length of stay, obstetric intervention, congestive cardiac failure, hysterectomy
• Fetal: Low BW, preterm birth, poor condition at birth, fetal growth restriction, stillbirth
• OSA and obesity significant risk factors for maternal death
• Underdiagnosed
• Prevalence increasing due to rising obesity rates
• Need to consider universal pre-pregnancy/pregnancy screening
• Appropriate screening modality – PSG impractical
• Treatment during pregnancy?
Management
• Ideally optimize maternal sleep prior to pregnancy
• Optimise pre-pregnancy maternal condition (weight, glycemic control etc)
• Consider high risk if SDB diagnosed
• Consider referral to a sleep/respiratory physician
• Anaesthetic and obstetric medicine/MFM referrals
• Screening and monitoring for GDM and Hypertension
• Avoid narcotics and other sedating agents
• Careful intrapartum management
• Wound care
• Use of CPAP pre and post operatively (and antenatally?)
Thank You
Questions?