Sleep Disorders in Perinatal Women

Sabra M. Abbott, MD, PhD, Instructor
Hrayr Attarian, MD, Associate Professor
Phyllis C. Zee, MD, PhD, Benjamin and Virginia T. Boshes Professor of Neurology
Affiliation: Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA

Insufficient sleep is prevalent in the general population, influenced by multiple factors:
- Environmental factors
- Psychosocial factors
- Medical disorders
- Psychiatric disorders
- Specific sleep disorders (e.g., insomnia, circadian rhythm disorders, OSA, RLS)
Prevalence Among Women: Women report higher sleep disturbances than men throughout life.
During the perinatal period, common sleep disorders may get exacerbated, and treatment options may shift, particularly for:
- Insomnia
- Narcolepsy
Emerging understanding of circadian rhythms affecting fertility and perinatal health.

Importance of Sleep: Critical biological function for health and well-being.
Governed by:
- Sleep Homeostatic Process: Increases with time awake, dissipates during sleep.
- Circadian Rhythm: Daily cycle regulating sleep-wake propensity.
Hormonal Influences: Gonadotropic and sex hormones affect sleep quality and sleep disorder risks, notably during pregnancy and postpartum.

Statistics:
- ~40% of pregnant women report getting good sleep only a few nights a month or less.
- ~30% of postmenopausal women report similar sleep difficulties.
Health Implications:
- Inadequate sleep correlated with negative outcomes:
- Mood disturbances
- Appetite regulation
- Insulin resistance
- Inflammation
- Autonomic function
- Sleeping disorders linked to higher risk of depression, obesity, diabetes, hypertension, cardiovascular diseases, and mortality.
Importance for Healthcare Providers: Obstetricians and gynecologists should routinely inquire about sleep quality during perinatal care.

OSA prevalence exacerbated by physiological changes in pregnancy.
Physiological Changes:
- Increased intra-abdominal pressure, diaphragm elevation due to gravid uterus.
- Decrease in functional residual capacity leading to physiological adaptations:
- Increase in minute ventilation
- Higher arterial oxygen levels
- Lower arterial carbon dioxide levels
Consequences:
- Increased risk of hypoxemia and obstructive sleep apnea.
- Changes in sleep position (supine) worsening OSA and leading to upper airway collapse.
- Weight gain in pregnancy can further exacerbate existing OSA.
Incidence of Habitual Snoring:
- Increases from 4% in non-pregnant to 25% during pregnancy.
- Studies show mixed outcomes on the fetal impact of habitual snoring related to OSA.
Impact on Fetal Outcomes:
- Increased risk of intrauterine growth retardation (IUGR) and adverse fetal outcomes linked to OSA and maternal hypoxemia.

Disorder	Diagnosis	Non-Pharmacological Treatment	Pharmacological Treatment
Obstructive Sleep Apnea	Polysomnogram	Auto-continuous positive airway pressure (CPAP)	None
Restless Legs Syndrome	Clinical History; Ferritin (less useful)	Exercise; Massage	Iron and Folate
Insomnia	Clinical History	Cognitive-Behavioral Therapy	Diphenhydramine
Narcolepsy	Polysomnogram with Multiple Sleep Latency Test	Protected sleep; Scheduled Naps	None
Shift Work Sleep Disorder	Clinical History	Regular Sleep-Wake Schedule; Bright Light Therapy	None

Defining gRLS: A movement disorder of dopaminergic dysfunction characterized by lower limb restlessness, worsening at night.
Prevalence: Occurs in 12-26% of pregnant women, often worsening with progression of pregnancy and resolving after delivery.
Diagnosing gRLS:
- Criteria include:
1. Urge to move legs due to uncomfortable sensations.
2. Temporary relief with movement.
3. Symptoms worsening at rest/inactivity.
4. Onset/evening symptom worsening.
Treatment Challenges:
- Most RLS medications are not FDA-approved for pregnancy.
- Recommendations include iron and folate supplementation, along with non-pharmacological treatments (exercise, massage).

Frequency: 52-61% of women report disrupted sleep during late pregnancy.
Correlations with Mental Health: Insomnia is closely associated with gestational depression.
Average sleep duration drops to about 7 hours, with some women reporting as little as 3-4 hours.
Insufficient sleep linked to complications like prolonged labor and increased cesarean section rates.

Condition Overview: Characterized by excessive sleepiness, cataplexy, sleep paralysis, and hallucinations.
Treatment Concerns: Many medications for narcolepsy have unknown safety profiles in pregnancy. Treatment often involves adjusting the patient's regimen or focusing on non-pharmacologic strategies to manage symptoms.
Complications during Pregnancy: Increased risks of higher pre-pregnancy BMI, glucose metabolism issues, and potential for emergency cesarean delivery as a result of cataplexy during labor.

Significance: The circadian system drives internal timing relative to the external environment, affecting health.
Disruption due to factors like shift work can lead to negative health consequences, including fertility issues and pregnancy complications.
Night shifts and chronic light exposure linked to adverse outcomes such as small gestational age, fetal loss, and potentially preterm delivery.

Normal function of circadian rhythms is crucial for maternal and fetal health.
Special attention should be paid to work schedules and potential sleep disorders in pregnancy, as they significantly affect outcomes.

Addressing sleep quality and disorders in the perinatal period is vital for improving health outcomes for mothers and children.
OSA, gRLS, insomnia, and circadian rhythm disturbances represent common but often unrecognized challenges that require proactive management during pregnancy.

Comprehensive referencing of studies regarding sleep disorders, hormones, and sleep quality.