Elsevier

Sleep Medicine

Volume 38, October 2017, Pages 50-57
Sleep Medicine

Original Article
Obstructive sleep apnea in pregnancy is associated with adverse maternal outcomes: a national cohort

https://doi.org/10.1016/j.sleep.2017.06.035Get rights and content

Highlights

  • OSA is associated with an increased risk of adverse pregnancy-related outcomes such as preeclampsia and gestational diabetes.

  • Risk of having an admission to the intensive care unit and the risk of hysterectomy is increased.

  • Obstructive sleep apnea is associated with severe maternal medical and surgical morbidities.

Abstract

Objective

Pregnancy and the obesity epidemic impacting women of reproductive age appear to predispose women to obstructive sleep apnea (OSA) in pregnancy. The aim of this study is to examine the association between OSA and adverse maternal outcomes in a national cohort.

Methods

The National Perinatal Information Center in the US was used to identify women with a delivery discharge diagnosis of OSA from 2010 to 2014. We used the International Classification of Diseases, ninth Revision to classify OSA diagnosis and maternal outcomes.

Measurements

The sample consisted of 1,577,632 gravidas with a rate of OSA of 0.12% (N = 1963). There was a significant association between OSA and preeclampsia (adjusted odds ratio (aOR) 2.22, 95% confidence interval (CI) 1.94–2.54), eclampsia (aOR 2.95, 1.08–8.02), and gestational diabetes (aOR 1.51, 1.34–1.72) after adjusting for a comprehensive list of covariates which includes maternal obesity. OSA status was also associated with a 2.5–3.5-fold increase in risk of severe complications such as cardiomyopathy, congestive heart failure, and hysterectomy. Length of hospital stay was significantly longer (5.1 + 5.6 vs 3.0 + 3.0 days, p < 0.001) and odds of an admission to an intensive care unit higher (aOR 2.74, 2.36–3.18) in women with OSA.

Conclusions

Compared to pregnant women without OSA, pregnant women with OSA have a significantly higher risk of pregnancy-specific complications such as gestational hypertensive conditions and gestational diabetes, and rare medical and surgical complications such as cardiomyopathy, pulmonary edema, congestive heart failure, and hysterectomy. OSA diagnosis was also associated with a longer hospital stay and significantly increased odds for admission to the intensive care unit.

Introduction

Pregnancy appears to predispose women to the development of obstructive sleep apnea (OSA) due to dynamic physiological changes [1]. Furthermore, the obesity epidemic now affects women of childbearing age [2] and is likely a major contributor to OSA in this young population. Wisconsin Sleep Cohort data show that the prevalence of OSA exceeds 10% in pre-menopausal women [3], suggesting that a good proportion of women are entering pregnancy with this condition, though it likely remains under-recognized [4].

Recent studies have shown a significant association between OSA and adverse pregnancy-related outcomes. Associations between OSA and hypertensive disorders were demonstrated in prospective [5], [6] and population studies [7], [8], [9] in Asia, North America, and Australia. Sleep-disordered breathing and OSA are also associated with gestational diabetes [10], [11], [12]. Preeclampsia and gestational diabetes impact immediate maternal [13], fetal [14], and neonatal [15], [16] health, as well as long-term metabolic [17], [18] and cardiovascular health in women [19], [20] and children [21], representing a substantial public health and financial burden. Hence, identifying the impact of OSA on the health of the mother and her offspring can help set the stage for future research assessing targeted screening and interventions in at-risk populations in an effort to modify the immediate and long-term health of the mother.

Data from the general population have linked OSA with cardiovascular complications [22], [23]. Such complications are rare in the young pregnant population and associations with OSA would be difficult to ascertain in prospective studies. As such, national cohorts with large datasets would be ideal for examining these complications.

The goal of this study was to examine the association of a diagnosis of OSA with adverse pregnancy outcomes such as gestational hypertensive disorders and gestational diabetes, and less common medical complications. We postulated that, compared to gravidas without the diagnosis, those with OSA would be at an increased risk of these adverse outcomes.

Section snippets

Study population and setting

The National Perinatal Information Center (NPIC) data is a membership organization comprised of perinatal centers across the United States (US) that submit quarterly clinical data to the Perinatal Center Data Base (PCDB). The PCDB dataset was used to identify women who had a delivery discharge from 2010 to 2014 at 95 different US hospitals. The dataset consisted of maternal characteristics, diagnosis codes based on the International Classification of Diseases, ninth Revision (ICD-9), and

Hospital characteristics

Hospitals in the southern part of the United States provided 43% – the highest proportion – of all patients, see Table 1. Hospitals in metropolitan areas, teaching hospitals, and hospitals with more than 5000 deliveries per year contributed the most to the dataset (97.2%, 73.6%, and 45.1%, respectively).

Maternal demographics

The sample consisted of 1,577,632 deliveries, of which 1963 women (0.12%) had a diagnosis code of OSA. Coding for OSA increased from 0.10% in 2010 to 0.16% in 2014. Mothers with OSA were older,

Discussion

In this national cohort, pregnant women with OSA were significantly more likely to develop adverse events. This study is the first to show a higher risk of ICU admissions and hysterectomy among pregnant women with OSA and confirms previous findings in another national cohort [8] that OSA is also associated with rare conditions such as cardiomyopathy, congestive heart failure, and pulmonary edema. A diagnosis of OSA was found to be associated with a higher risk of developing gestational

Conclusions

Pregnant women with OSA have a significantly higher risk of having morbid pre-pregnancy conditions and pregnancy-specific complications such as gestational hypertensive conditions and gestational diabetes. Pregnant women with OSA also have a longer length of hospital stay and higher odds of an admission to the ICU and of having rare cardiovascular and surgical complications than women not diagnosed with OSA.

Author contributions

Study concept and design: GB, MB, HL, JM, DC, KRM; data acquisition: GB, VD, DC, JM; data analysis and/or interpretation: GB, VD, HL, MB; manuscript writing and/or critical revisions for important intellectual content: GB, VD, MB, HL, JM, DC, IT, KRM. All the authors have read and approved the final version of the manuscript.

Acknowledgments

GB is funded by the National Institutes of Health R01HD078515 and R01HL130702 and is the guarantor of the paper and takes responsibility for the integrity of the work as a whole, from inception to published article.

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