OB/GYN Francesca L. Facco, MD, posits a new approach to screening for sleep disorders during pregnancy.

Healthy sleep—and the lack of it—is gaining ground as a marker of an individual’s physical well-being. Sleep-related research and advocacy activities focus on an ever-widening range of issues, including the prevalence of sleep disorders in children, the relationship between lack of sleep and weight gain, and the impact of yoga on sleep health among the elderly. As advocacy and awareness activities ramp up, areas of focus continue to expand.

Sleep health during pregnancy is one of these areas. As within the wider community, sleep serves many important functions that contribute to the overall health of the expectant mother and her baby. But unlike the general population, due to the high incidence of sleep disturbances that most pregnant women experience, sleep problems during pregnancy can be looked upon as normal. Evaluation for sleep-disordered breathing (SDB) might be overlooked. Efforts toward building awareness of SDB during pregnancy, including its detection and impact, are underway.

Francesca L. Facco, MD, an obstetrician-gynecologist at the University of Pittsburgh Medical Center, is at the forefront of these efforts. In addition to her clinical practice in maternal fetal medicine, through her research she is actively engaged in the study of sleep and its impact on pregnancy.

Current studies being undertaken by Facco and by other researchers are examining the many aspects of sleep health and pregnant women. Local and multicenter efforts are underway to explore a range of topics, including sleep duration, sleep timing, and SDB in pregnancy. Through these studies, researchers seek to understand how poor sleep may impact a mother’s health, including her risk of a hypertensive disorder of pregnancy, gestational diabetes, or preterm birth.

“Just as we focus on diet and exercise, we should be thinking about sleep as an important variable for a healthy pregnancy,” Facco says. “We have to recognize that a certain proportion of our patients might be suffering from sleep apnea, which too often goes unrecognized in young women of reproductive age. If pregnant women are presenting with significant sleep complaints, it might be indicative of an underlying sleep disorder.”

Need for a New Screening Protocol

 Francesca L. Facco, MD

Because excessive daytime sleepiness (EDS) is a very common complaint during pregnancy even in women without obstructive sleep apnea, EDS questions are not likely to be specific for sleep apnea in pregnancy, Francesca L. Facco, MD, says.

One of the primary challenges to diagnosing sleep disturbances, such as sleep apnea, during pregnancy is the lack of an effective screening option. “Widely used screening tools like the Berlin Questionnaire and the Epworth Sleepiness Scale (ESS) were not tested with pregnant women prior to their employment in the general population,” Facco says. “When these questionnaires were tested during pregnancy, they performed poorly.”

Facco served as lead investigator on a 2011 study that demonstrated the limitations of traditional screening tools during pregnancy. The study was published in the Journal of Clinical Sleep Medicine (2012 Aug 15;8(4):389–394). “In many sleep apnea screening tools, part of the scoring depends on an evaluation of sleepiness,” Facco says. “In pregnancy, sleepiness and fatigue are common symptoms, and are not necessarily indicative of an underlying sleep disorder.”

Facco’s study contrasted traditional screening tools with a simpler four-variable approach that included self-reported frequent snoring, chronic hypertension, body mass index, and age. The alternative screening method was found to predict sleep apnea with greater specificity.

Ongoing efforts seek to validate these findings in a larger cohort in order to establish evidence-based screening tools. “We’re not at a stage where we’re recommending universal screening of pregnant women for sleep apnea as a routine part of prenatal care,” says Facco. “There are still a lot of questions to be answered regarding how best to screen, and if screening and treatment will result in improvement of outcomes.”

As research continues, Facco urges obstetricians to pay attention to patients who self-present with sleep issues, particularly if they are at high risk due to age, weight, or hypertension. “If their patients are coming in with significant sleep complaints,” she says, “obstetricians should pay attention and not hesitate to address these symptoms.”

In turn, sleep specialists can work to raise awareness of sleep disorders during pregnancy within the OB/GYN community. While a prenatal screening protocol is yet to be established, Facco suggests sleep specialists reach out to obstetricians to help them understand the inaccuracy of traditional SDB screening methods on pregnant women, and make them aware of the specialized resources that are available to help their patients who have sleep disorders. “It’s important to be collaborative,” she says. “Obstetricians should refer women who are having these issues during pregnancy to a sleep specialist for treatment.”

Healthier Pregnancies

Magee-Womens Hospital

Facco practices at the Magee-Womens Hospital of University of Pittsburgh Medical Center.

Facco estimates that 3% to 6% of pregnant women will experience sleep apnea in early pregnancy, and 5% to 10% will experience it in later trimesters. High-risk populations, including older or obese women, have a higher rate of occurrence. The condition may or may not be preexisting; pregnancy-associated weight gain and fluid retention can exacerbate an existing condition, or, indeed, promote its development.

Women who have sleep apnea when they enter pregnancy may not be aware that they have the condition, and formal diagnosis and possible treatment could be missed. Those who develop sleep apnea during pregnancy usually develop a mild form of the condition. Resolution of incident sleep apnea may likely be dependent on postpartum weight loss.

Pregnant women encounter a range of sleep issues in addition to sleep apnea, including restless leg syndrome, insomnia, and poor sleep hygiene, Facco observes. Better understanding of how all of these issues impact pregnant women and their fetuses can play a vital role in maintaining healthy pregnancies.

“Helping pregnant women who are complaining about poor sleep get better sleep can not only help them feel better, but potentially make for a healthier pregnancy,” Facco says. “This is an area of emerging research, so obstetricians and sleep specialists should stay tuned.”

A deeper understanding of the interdependence between sleep and health has been a welcome outgrowth of Dara O’Brien’s role as a contributor to Sleep Review. As might be expected from a reformed night owl, her sleep habits continue to evolve.