Obstructive sleep apnea (OSA) is a complication in 3.6-32% of pregnancies. OSA is characterized by partial or complete airway collapse during sleep, resulting in varying degrees of oxygen desaturation and micro-arousals, with the associated release of catecholamines and reactive oxygen species. This results in increased inflammation, dysregulation of endothelial function, and increased blood pressure. The effects of sleep apnea and its treatment during pregnancy remain poorly understood. Gaps in knowledge exist regarding the best screening tools for OSA during pregnancy, whether sleep apnea that is specific to pregnancy (versus preexisting) is harmful, and whether the treatment of sleep apnea reduces the risk of adverse pregnancy outcomes associated with this condition.
Systematic reviews and meta-analyses have demonstrated an increased risk of adverse pregnancy outcomes when OSA is diagnosed. OSA is associated with an increased risk of hypertensive disorders of pregnancy, such as gestational hypertension or preeclampsia, which are presumably mediated by endothelial dysfunction. OSA also increases the risk of developing gestational diabetes, presumably due to reductions in glucose metabolism and glucose transport, and to increased beta-2 islet cell death within the pancreas. OSA is also associated with intrapartum and postpartum complications, such as operative vaginal delivery, cesarean delivery, post-operative wound complications and neonatal outcomes such as preterm birth and low birthweight.
The existing screening tools for sleep apnea during pregnancy are limited. Many of the established tools for non-pregnant adults perform poorly during pregnancy. The Berlin Questionnaire and Epworth Sleepiness Scale, for example, performs poorly during pregnancy. STOP-BANG is also limited for the evaluation of pregnant women due to its emphasis on male sex and age over 50 years.
Whether CPAP helps to reduce the incidence of adverse pregnancy outcomes in pregnant women with sleep apnea remains to be seen. Some small early studies have demonstrated reduced preeclampsia, and a more recent trial also suggested a reduction in hypertensive disorders of pregnancy. Other benefits may include pregnancy prolongation, fewer cesarean births, and a higher five-minute Apgar score. However, there is still a lack of published evidence and significant gaps in knowledge remain.
In this issue we will cover what is known and what remains to be discovered regarding the diagnosis, impact, and treatment of sleep apnea during pregnancy.
Assoc. Prof. Kathleen Antony and Dr. Mihaela Bazalakova
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