It's no secret that sleep can be elusive during pregnancy. But about 20 percent of pregnant women are actually struggling with obstructive sleep apnea (OSA) – oftentimes without knowing it.
A common condition that affects nearly 30 million people in the United States, OSA causes breathing issues during sleep due to repeated airway obstruction. Excess weight, throat anatomy limitations, and brain or hormonal changes are a few reasons the throat doesn’t relax as it should during sleep.
Though pregnant women are at increased risk for OSA due to body changes, the condition often goes undiagnosed or undertreated. This may be because OSA symptoms overlap common pregnancy side effects, such as headaches, heartburn, and morning nausea, as well as emotional changes such as anxiety and depression.
Sleep apnea during pregnancy can lead to long-term health complications, such as increased risk of high blood pressure, preeclampsia, gestational diabetes, or premature delivery. OSA also increases the risk of needing a cesarean section (C-section) delivery, having complications with anesthesia, and enduring a longer labor.
Maternal mortality rates in the U.S. are less than 1 percent. The National Institutes of Health data show the risk of death prior to discharge after delivery is 2.47 percent with OSA compared with 0.13 percent in patients who do not have OSA.
Fortunately, research shows that continuous positive airway pressure (CPAP) therapy is a safe and effective way to reduce such risks before, during, and after pregnancy.
I've invited family medicine doctor Mahdi Awwad, M.D., to discuss how we diagnose OSA in pregnancy and help pregnant patients sleep better. Dr. Awwad co-authored an article on OSA in pregnancy in the journal Psychiatric Annals with UT Southwestern sleep medicine expert Safia Khan, M.D., and colleagues Sarah Rizvi, M.D., and Numan Choudhry, M.D.
What causes OSA in pregnancy?
The hormones estrogen and progesterone rise through each trimester. Progesterone specifically stimulates certain receptors in the brain that help drive your breathing and oxygen consumption.
OSA symptoms tend to get worse as pregnancy progresses. Your expanding uterus may restrict lung functional capacity by 20 percent on top of normal reductions typically seen during sleep, and your oxygen consumption increases approximately 20 percent. That means you'll need to take more breaths per minute at a time when your body should be relaxing.
At the same time, the capillaries in your body become engorged with blood, leading to increased fluid retention in the throat, which can cause the breathing space to narrow.
That means your body is more taxed during breathing, especially at night as you're lying down, which puts more pressure on the airway. This is also what leads to annoying symptoms such as pregnancy rhinitis and nosebleeds, which can also disrupt sleep.
Related reading: How pregnant moms can get better sleep
Since OSA symptoms mimic the side effects of pregnancy – which is also known to cause insomnia – many pregnant patients may go undiagnosed. And many women with OSA may not snore. Instead, they experience the ill effects of inadequate sleep: mood changes, anxiety, and general fatigue. Some patients may confuse an apnea episode with having a nightmare.
We follow a multistep process to properly diagnose patients and help them get the care – and restorative sleep – they need.
Diagnosing sleep apnea in pregnant patients
Talking with you (and your partner)
We'll have a conversation about your sleep hygiene – your bedtime routines and any struggles you've noticed. Along with this, we'll talk about how you feel upon waking, such as whether you have a headache or still feel tired after a night's sleep.
However, many patients don't realize they're not breathing or sleeping well until their partner complains about symptoms that keep them awake. So, it's important to get your partner's perspective about changes in your mood, nighttime breathing, and sleep patterns.
We will also examine you for physical risk factors of OSA, such as:
- A neck circumference of 16 inches or larger
- Having limited space in the back of the throat when you say "ahh"
- Being overweight (before or during pregnancy)
- High blood pressure
- Low blood oxygen level
If we suspect sleep apnea based on your data and health history, we will refer you to a sleep medicine doctor to confirm the diagnosis.
The gold-standard test to diagnose OSA is an overnight sleep study (polysomnogram). During this test, you'll sleep in a private room where a sleep medicine expert will monitor your breathing, heart rate, and the depth of your sleep cycles using painless body sensors and video monitoring. Depending on your other health needs, you may qualify for a home sleep study. Home tests gather similar data using portable devices.
Polysomnograms provide data about how many episodes of symptoms you experience in the night. With a mild case of OSA, you may have 15 or fewer episodes. Moderate cases cause 15 to 29 episodes nightly, and severe cases cause 30 or more.
The most effective treatment for sleep apnea, CPAP therapy involves wearing to bed a small mask or nasal canula that delivers continuous airflow with a little moisture into your airways.
It may take a few weeks to feel comfortable sleeping with the CPAP, but the benefits can be substantial. Research shows that just one night of CPAP therapy can substantially decrease blood pressure in pregnant patients.
Getting consistent, restful sleep is associated with long-term health benefits such as:
- More energy
- Better mental and emotional clarity
- Decreased risk of high blood pressure, heart disease, and diabetes
When you go to the doctor during pregnancy, bring your CPAP machine, mask, and other items to ensure everything is working properly. This is a good time to switch out any worn or damaged items. Making sure everything is working properly will help you maintain adequate oxygenation.
Some patients worry they'll look unattractive wearing a CPAP mask, so they delay the care and restful sleep their bodies need during pregnancy. But once they start to feel better and more energetic, the benefits outweigh the stigma. CPAP therapy can be a win-win for pregnant patients and their growing families.
Patients with mild OSA may benefit from sleeping with their head and/or upper body elevated. Some patients may also benefit from wearing a mouthguard-type device that holds the lower jaw forward slightly, potentially opening the back of the throat. However, these options don't provide airflow and may not effectively treat the root of the problem.
Losing weight before or after pregnancy may also help improve or resolve symptoms. Talk with your Ob/Gyn or sleep medicine doctor about the best strategies to achieve a healthy weight.
In some patients, OSA may resolve a few weeks to months after their baby is born. But we find that many patients had an underlying case of OSA prior to pregnancy. These patients typically continue to benefit from CPAP therapy and a team approach to their long-term care.
If you think you have sleep apnea – or symptoms – talk with your doctor. Early diagnosis can help prevent complications and improve the health of your growing family.
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