Sleep Apnea and Pregnancy

Sleep Apnea and Pregnancy-What Your SleepinessMay Be Telling YouRobin Burns of Fruitland, Idaho, felt tired during her three pregnancies but chalked it off to the way a woman is supposed to feel when she is expecting. Burns, who has three children, Chantz, 7, Kayla, 10, and Alison, 11, came to a crisis point when she fell asleep at the wheel. She eventually learned she had sleep apnea, a condition when repetitive or recurrent breathing pauses occur at nighttime during sleep.

“After Kayla was born, I found I was very tired all the time,” Burns says. “I was just exhausted. I went to my OB/GYN and told him, ‘I’m just dragging. I’m just exhausted.’ He said, ‘You are a mother of a brand-new baby. You work full time. I just think you are just normal.'”

Women with sleep apnea often have conditions such as preeclampsia, small-for-gestational-age births or hypertension associated with the pregnancy.

But Burns suspected the problem was something deeper. Her husband, Karlen, a registered nurse, noticed she stopped breathing for periods while she was asleep at night. “I was falling asleep while driving,” she says. “I could close my eyes for one second and literally would fall asleep. I needed naps at work. It was more than just feeling overwhelmed about being a new mom. I continued being tired, and then, after my son was born, I went to my primary care physician and he referred me to a specialist for a sleep study.”

Burns says a sleep specialist tested her for sleep apnea. Now she never goes a night without continuous positive airway pressure, or CPAP, therapy. Burns says she wishes she could have been diagnosed with sleep apnea during or before her pregnancies.

“The first night I was on CPAP I noticed a difference,” Burns says. “That morning I woke up so refreshed, so incredibly like a new person. It was like 100 percent improvement.”

Because it’s difficult for some women to distinguish sleep apnea symptoms from normal pregnancy fatigue, Burns encourages women to have a sleep study. “I think you are tired anyway when you are pregnant, but it’s a different type of tired,” she says. “It’s like pulling several all-nighters when you have sleep apnea. You can’t keep your eyes open.”

Studying Sleep Apnea

Sleep Apnea and Pregnancy-What Your SleepinessMay Be Telling YouDr. Pien, a sleep-disorders physician, says obstructive sleep apnea is a condition that affects 2 to 4 percent of the general population. “Some of the effects of sleep apnea in the general public is it causes daytime sleepiness and has been linked to increased risks for high blood pressure and other adverse cardiovascular effects,” Dr. Pien says.

While sleep apnea is not the direct cause of depression, Dr. Pien says depression is common in patients with obstructive sleep apnea. “In pregnant women, the research I have been doing is to look at how commonly sleep apnea develops in pregnant women,” she says.

Dr. Pien says other case reports and existing literature on the topic suggest women with sleep apnea often have conditions such as preeclampsia, small-for-gestational-age births or hypertension associated with the pregnancy. Also, studies suggest women who developed loud, habitual snoring during pregnancy might be more likely to have problems such as high blood pressure during pregnancy or preeclamsia.

“What we have been finding is among some groups of women sleep apnea is quite common,” Dr. Pien says. “It looks as if the strongest risk factors for sleep apnea during pregnancy is starting out the pregnancy overweight. One of the other things we were interested in learning was whether the amount of weight a woman gains during pregnancy was likely to increase her risk [for sleep apnea] during pregnancy. So far it seems the weight you start out with is more important than the weight gained during pregnancy.”

Dr. Pien says she was surprised to find few of the women in her study who had preeclampsia or gestational diabetes also had sleep apnea. Some research suggests sleep apnea may adversely affect labor, says Dr. Pien. Pregnant women who get fewer hours of sleep are more likely to have longer labors and get C-sections, Dr. Pien says.

Normal Sleep Problems or Sleep Apnea?

Dr. Pien says complaints about their sleep were common in nearly all of the women she studied. “Sleepiness is a very common complaint or symptom that women experience regardless of whether they have sleep apnea or not,” she says. “Snoring is common, so if a woman develops snoring it does not mean she has obstructive sleep apnea because probably up to 20 percent of women are going to develop snoring by the end of pregnancy. However, most of them don’t actually have sleep apnea.”

Dr. Pien says women who are pregnant should be alarmed if they have symptoms such as gasping, choking and difficulty breathing at night. She says sometimes women’s husbands or partners might notice they have episodes where their breathing stops at night. “Those are symptoms that would make them more concerned they have sleep apnea,” she says.

Because of all the physical and hormonal changes occurring during pregnancy, it’s not unusual for women to suffer from sleep disturbances. Many women who have sleep apnea simply don’t notice the symptoms until they become pregnant and the symptoms become more profound. “With the fetus growing, and the uterus getting bigger and diaphragm getting pushed up, it’s harder to breathe,” Dr. Pien says. “And so that might be something that makes sleep apnea, the symptoms, become more prominent. Especially the high estrogen levels that help the uterus cause other tissues throughout the body to swell, and that can include tissues in the mouth and nose and upper airway.”

Women who are pregnant sometimes have nightmares about whether or not they will be good mothers. While it’s common to have anxiety, it’s not normal to have repetitive dreams about being suffocated, especially if your partner or husband notices you are not breathing while sleeping. “Dreams, even frightening dreams about pregnancy, are pretty common during pregnancy,” Dr. Pien says. “If you are waking up feeling you are choking or gasping, that can be a symptom of sleep apnea.”

Getting Help

Women who think they may have sleep apnea should first talk to their obstetrician about it. Depending on what the obstetrician thinks about the seriousness of the symptoms, he may send the woman to a sleep disorders physician or internist for a more thorough history taking and evaluation, according to Dr. Pien.

Dr. Pien says a sleep specialist will probably recommend an overnight sleep study. “[During the sleep study] the sleep stages are monitored and breathing and oxygen levels and heart rates are also monitored so we can see if there are breathing pauses occurring and associated drops in the body’s oxygen level that can be potentially harmful to the fetus,” she says. Instead of prescribing medicine, the sleep specialist will most likely use the most common treatment for sleep apnea – CPAP therapy.

“What that is, is a mask that fits over the nose, or sometimes people use what we call nasal pillows that plug into the nose,” Dr. Pien says. “It’s connected via tubing to a machine that is the size of a shoebox. It delivers air under pressure. The air helps to hold the airway open so these breathing pauses no longer occur and air and oxygen are all able to make it down into the lungs so that the rest of the body can utilize that oxygen.” CPAP can be set up in a patient’s home.

For most women, sleep apnea is found to be a temporary condition during pregnancy associated with the changes occurring in her body. After the pregnancy, a woman might be asked to continue to wear the CPAP until her weight returns to the pre-pregnancy weight. Another follow-up sleep study may be performed to make sure the condition has gone away, Dr. Pien says.

Women who have a more severe problem with sleep apnea my need surgical options such as uvulopalatopharyngoplast, or UPPP, a procedure that removes excess tissue in the throat to make the airway wider. The surgery allows air to move through the throat more easily when a person breathes, which decreases the severity of obstructive sleep apnea. Dr. Pien says she would not recommend UPPP for pregnant women because of the risks surgery involves.

Dr. Pien says pregnant women should be aware of the fact that sleep needs increase during pregnancy. “There has been data to show, in especially the first trimester, [that] women are sleepy and are needing between 30 and 45 more minutes of sleep in the early part of pregnancy than before pregnancy,” she says. “By the third trimester there are sleep disturbances at nighttime because they can’t get comfortable.”

She says some women compensate for lost sleep by taking naps during the day, which is a healthful option. It’s important for a woman to get plenty of rest after giving birth as well.

How Sleep Apnea Affects the Fetus

Nancy Collop, a sleep medicine specialist with Johns Hopkins University in Baltimore, Md., says having sleep apnea is not just unpleasant for the woman, but also for her unborn child. “Perhaps the more serious effect might be the effect on the child of lack of oxygen,” Collop says. “When they have breathing interruptions, they might pause as short as 10 seconds but sometimes as long as a minute. So they may drop their oxygen levels to quite severe levels. The effect of the lack of oxygen on the baby can be profound.”

Collop says the greatest risk for the baby due to lack of oxygen is to brain development. “Of all the organs in our body, the brain is most sensitive to lack of oxygen,” Collop says. Women who have high blood pressure and other medical conditions that put them in the high-risk pregnancy category are more likely to end up with a C-section.

“People who have sleep apnea are much more likely to have high blood pressure, much more likely to have an increased risk of stroke and heart disease,” Collop says. “Whether that happens in pregnant patients is not well studied.”

Finally, whether you have sleep apnea or not, it’s important to get plenty of sleep for your mental and physical health. Collop says most adults need at least eight hours of sleep. Pregnant women who are waking up several times during the night due to sleep apnea or simply because they need to use the restroom may need to stay in bed longer to achieve eight hours of sleep. She says sleep disruption is definitely related to neuro-cognitive behavior, which means a woman who is sleep deprived may have a shorter attention span.

So if your short-term memory seems foggy, tie a string around your finger to remind yourself to get plenty of sleep. And remember to see your doctor about conducting a sleep study to rule out sleep apnea as a cause.

Signs You May Have Sleep Apnea

You have gasping or choking.

Another person witnesses you stop breathing while sleeping.

You have night terrors repeatedly in which someone is suffocating you.

You started out your pregnancy obese and continue to gain more than the recommended amount of weight for pregnancy and also suffer with other symptoms such as falling asleep while driving.

You experience stuffy nose and congestion associated with not breathing for 10 seconds to a minute.

Signs Your Poor Sleep Is “Normal”

You lose sleep because you have to urinate frequently during the night.

Your husband complains of your snoring but has never noticed you stop breathing.

You feel tired during the day.

You experience restless leg syndrome, which triggers a crawling sensation in the legs that keeps you awake at night.

You gained more than the recommended weight during your pregnancy. Indigestion and feeling bloated keeps you awake at night.