CE Expiration Date: May 5, 2025
CEU (Continuing Education Unit):2 Credit(s)
AGD Code: 750
This self-instructional course for dentists aims to show sleep related breathing disorders during pregnancy increase the risk of adverse maternal and fetal outcomes. Each of these conditions are independently associated with inflammation, oxidative stress from hypoxia, and increased sympathetic nervous system activity. When they occur together however, the health consequences are even more severe. The adverse maternal outcomes include: hypertension, preeclampsia, diabetes, thromboembolism, and cardiomyopathies. The adverse fetal outcomes include: preterm birth, low birth weight, changes in developing palate morphology, as well as growth restrictions that potentially lead to airway deficiencies in the neonate and into adolescence. As SRBD in pregnancy is under diagnosed, there is an opportunity to improve the health outcomes of mother and fetus through screening, diagnosis and treatment.
Dental Sleep Practice subscribers can answer the CE questions by taking the quiz to earn 2 hours of CE from reading the article. Upon completion of this course, participants will be able to:
- Understand the pathophysiologic crossovers of pregnancy and SRBD.
- Learn the impact of maternal SRBD during pregnancy on the developing fetus and how it may increase the risk of development of SRBD in the neonate and developing child, even into adulthood.
- Appreciate the importance of screening and treatment to reduce the risk of adverse maternal and fetal outcomes.
In this CE, Dr. Steve Lamberg shows that having a sleep-related breathing disorder during pregnancy can be detrimental to both mother and baby.
by Steve Lamberg, DDS, D.ABDSM
Ample evidence exists showing Sleep Related Breathing Disorders or SRBD, have a negative impact on maternal and fetal outcomes. A growing body of evidence reveals therapeutic intervention directed at SRBD creates positive health outcomes.
SRBD cover a spectrum of medical conditions ranging from Upper Airway Resistance Syndrome “UARS” through severe Obstructive Sleep Apnea “OSA” and are frequently accompanied by the symptom of snoring. The prevalence of OSA ranges from 7.8 to 77.2% in adults aged 30-69 years.1 Among obese pregnant women, 15%–20% have OSA and this prevalence increases along with body mass index and in the presence of other comorbidities.2 These prevalence statistics in women are considered to be significantly underestimated due to gender-related differences in diagnosis resulting from women underreporting symptoms as well as an increased prevalence of UARS that does not meet the criteria to be OSA. Airway resistance even without a cortical arousal can upregulate the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis causing a rise in blood pressure.3
A diagnosis of OSA as well as its key symptom of habitual snoring have been linked to hypertensive disorders of pregnancy, insulin resistance.4 gestational diabetes, and poor fetal outcomes. Habitual snoring means at least 3 nights/week and pregnant women who are habitual snorers have a 2-fold greater risk of gestational hypertension relative to non-snorers, although it has also been shown that snoring onset during pregnancy has worse outcomes than if habitual snoring existed pre-pregnancy.5,6
A diagnosis of SRBD has been linked to poor fetal outcomes.
During pregnancy as in menopause, women have an increased risk of SRBD attributable to changes in estrogen and progesterone as well as weight gain.7,8,9
Estrogen contributes to edema, vasodilation, and nasal congestion that could impact the upper airway by making it more collapsible while progesterone enhances respiratory drive creating a “vacuum effect” and could contribute to airway collapse.2 SRBD during pregnancy increase the risk of hypertensive disorders of pregnancy “HDP,” occurring in 1 of 10 pregnancies, and are associated with significant maternal morbidity and mortality.10,11
The study, employing the United States Healthcare Cost and Utilization Project-National Inpatient Sample, examined 7,907,139 deliveries and found women diagnosed with OSA were at higher risk of having pregnancies with preeclampsia [odds ratio (OR) 2.2], eclampsia (OR 4.1), chorioamnionitis (OR 1.4), postpartum hemorrhage (OR 1.4), venous thromboembolisms (OR 2.7), and delivery by caesarean section (OR 2.1). Gestational diabetes as well as cardiovascular and respiratory complications were also more common among these women, as was maternal death, OR 4.2.12
Newborns of OSA mothers were at elevated risk of being premature, OR 1.3 and having congenital abnormalities, OR 2.3.12 The higher risk of congenital anomalies and resuscitation at birth in neonates of mothers with OSA, emphasizes the importance of identifying OSA in pregnant women and women of reproductive age.13
Fetal growth restriction was also more prevalent and is the basis of the Sleep Apnea and Fetal Growth Restriction study (SAFER). Fetal growth restriction “FGR,” affecting 10% of all pregnancies, is a major contributor to fetal and neonatal morbidity and mortality with intrauterine, neonatal and lifelong complications. While previous studies have reported an association between low birthweight and elevated blood pressure (BP) in adulthood, the recent Raine study14 explored the association between intrauterine fetal growth restriction from 1440 women and BP of their adult offspring. Their data revealed evidence that restricted fetal growth was associated with significantly higher adult BP over two decades later that corresponded with a 10% higher risk of death due to heart disease and a 10% higher risk of stroke. This study further reinforces the importance of the early intrauterine environment and its influence on adult BP. OSA has been hypothesized to be a modifiable risk factor for FGR.15,16
Premature birth is one that occurs before 37 weeks of gestation or having a low birth weight. The short-term and long-term effects of preterm birth “PTB” on a child’s physical and psychological growth and development have been a hot topic of interest. The brain, lungs, and eyes are the most susceptible organs, but facial bones and palate morphology may also be affected. The prevalence or PTB ranges from 0-10% in children, and 10-70% in children with low birth weight. Palates of premature infants have narrower and deeper forms compared to the palates of non-premature infants. Additionally the mandibular arches are less developed and evidence shows that the lower the gestational age, the more the tooth development is delayed at age 9.17 Due to this, there is a greater risk of future malocclusion, difficulties in chewing or speaking, and aesthetic problems.18 Malocclusion traits including crossbite, open bite, midline shift, open bite, spacing, and Angle’s Class 2, occurred significantly more often in early pre-term EPT (83.3%) and very pre-term VPT (73%) children, compared with full-term (51.2%) children. Deep bite was the most common malocclusion trait in the EPT and the VPT group. Higher orthodontic treatment need was found for the preterm children.19 Inadequate growth and development of the jaws compromises the airway and leads to compensations, which have consequences including orthodontic problems.
A normal physiological component of healthy pregnancy is fetal movement, which has been used both formally and informally as a marker of fetal well-being. Reductions in fetal movement accompanies complications such as fetal growth restriction. It has been hypothesized that SRBD may link preeclampsia with reduced fetal movement and that treatment of sleep disordered breathing might improve fetal activity during sleep. A study by Blyton showed CPAP to be effective in improving fetal movements which suggests a pathogenic role for SRBD in reduced fetal activity and possibly other poor fetal outcomes associated with preeclampsia.20
Fetal hiccups were reduced in women with preeclampsia and through intervention with CPAP were found to increase, providing intriguing evidence of the pathogenic connection of airway and fetal health.21 Fetal hiccups may be a manifestation of programmed isometric inspiratory muscle exercise in preparation for postnatal respiratory function.22
A scoping review of the literature with meta-analysis shows that maternal sleep events such as OSA, sleep disruption, and time spent in certain body positions, may have negative effects on the fetus, resulting in altered growth, gestational length, and even death.23 As SRBD are a prevalent risk factor of gestational cardiometabolic disease, they are a potential therapeutic target to reduce cardiometabolic morbidity.24
Robust literature demonstrates SRBD as a consistent, strong, and positive predictor of gestational hypertension and preeclampsia, similar to studies of SRBD and hypertension in non-pregnant adults. A systematic review reported OR 2.4 of pregnancy related hypertension among women with habitual snoring or moderate to severe OSA.25
Maternal sleep events such as OSA, sleep disruption, and time spent in certain body positions, may have negative effects on the fetus, resulting in altered growth, gestational length, and even death.
Therapeutic intervention has been shown to improve health outcomes in women. In a study of 11 women with preeclampsia and mild SDB, one night of CPAP reduced mean systolic (128 mmHg vs 146 mmHg ) and diastolic (73 mmHg vs 92 mmHg) blood pressure compared with a baseline night without treatment in the same women.26 In another study, 12 women with preeclampsia, a single night of CPAP in the third trimester improved cardiac output and reduced peripheral vascular resistance, whereas no improvement occurred in a nontreated preeclampsia group.27 Larger sample sizes are needed to be powered to assess gestational outcomes. A phase III clinical trial is underway with 2,700 women to examine whether treating SDB in pregnancy reduces the risk of gestational hypertensive disease.28
Given our current level of knowledge, pregnant women who have even mild sleep apnea should be treated for their SRBD. Questionnaires are an effective and efficient way to educate patients and screen for SRBD, treatment of which will benefit maternal and fetal outcomes while possibly serving to optimize craniofacial growth from infancy into adolescence and beyond. It is time to consider vigilance of maternal SRBD as the first step towards the earliest intervention to prevent SRBD along life’s journey from neonate to adult.
Screening and treatment of SRBD in pregnant women requires an interdisciplinary approach. Dentists can and do play an essential role in the multidisciplinary care of patients with certain sleep related breathing disorders and are well positioned to identify patients, including pregnant women, at greater risk of SRBD. The American Dental Association encourages dentists to screen patients as part of a comprehensive medical and dental history to recognize symptoms such as daytime sleepiness, snoring or witnessed apneas and to evaluate risk factors such as obesity, retrognathia, age and hypertension. Whenever a risk is determined, patients can be referred to appropriate physicians for sleep testing and diagnosis. Pregnant women should undergo serial monitoring with questionnaires as SRBD increases from the first to the third trimester. If the onset of SRBD occurs during pregnancy, sleep testing 3-6 months postpartum is recommended to evaluate if the SRBD has been resolved. When SRBD is diagnosed, there are many treatment options including CPAP and oral appliance therapy. Dentists with training in dental sleep medicine can fabricate a custom oral appliance to optimize the airway and breathing pattern. There are also simpler temporary appliances that can be fit and delivered at the first visit if necessary.
Dentists and physicians can collaborate to enhance health outcomes of mother and fetus. We can even gift the expectant mother one of the many great books available to help her and her newborn along their way to optimal health.
The article “Can physicians and sleep dentists create lasting symbiotic relationships?” also discusses the importance of treating woman for sleep-related breathing disorders during pregnancy, to avoid life threatening complications. Read the article here: https://dentalsleeppractice.com/2676/.
- Benjafield A V, Ayas N T, Eastwood P R, et al. Estimation of the global prevalence and burden of obstructive sleep apnea: a literature-based analysis. Lancet Respir Med. 2019;7(8):687–698.
- Dominguez J E, Krystal A D, Habib A S. Obstructive sleep apnea in pregnant women: a review of pregnancy outcomes and an approach to management. Anesth Analg. 2018;127(5):1167–1177
- Lamberg S, Upper Airway Resistance Syndrome, Inside Dentistry, Jan 2021:60
- Laura Sanapo, Margaret H Bublitz, Alice Bai, Niharika Mehta, Geralyn M Messerlian, Patrick Catalano, Ghada Bourjeily, Association between sleep disordered breathing in early pregnancy and glucose metabolism, Sleep, 2022, zsab281
- O’Brien LM, Bullough AS, Owusu JT, et al. Pregnancy-onset habitual snoring, gestational hypertension, and preeclampsia: prospective cohort study. Am J Obstet Gynecol. 2012;207(6): 487.e1–487.e9
- Li L, Zhao K, Hua J, Li S. Association between sleep-disordered breathing during pregnancy and maternal and fetal outcomes: an updated systematic review and meta-analysis. Front Neurol. 2018; 9:91
- Young T, Finn L, Austin D, Peterson A. Menopausal status and sleep-disordered breathing in the Wisconsin Sleep Cohort Study. Am J Respir Crit Care Med. 2003; 167(9):1181–1185.
- Dunietz G L, Chervin R D, O’Brien LM. Sleep-disordered breathing during pregnancy: future implications for cardiovascular health. Obstet Gynecol Surv. 2014; 69(3):164–176.
- Balserak BI. Sleep-disordered breathing in pregnancy. Breathe. 2015;11(4):268–277.
- Zhang J, Troendle J, Levine R. Risks of hypertensive disorders in the second pregnancy. Obstet Gynecol. 2000;95(4, Suppl 1): S77.
- James PR, Nelson-Piercy C. Management of hypertension before, during, and after pregnancy. Heart. 2004;90(12):1499–1504.
- Eloise Passarella, Nicholas Czuzoj-Shulman, Haim A Abenhaim, Maternal and fetal outcomes in pregnancies with obstructive sleep apnea, J Perinat Med, 2021 Sep 15;49(9):1064-1070
- Ghada Bourjeily , Valery A. Danilack, Margaret H. Bublitz, Janet Muri, Karen Rosene-Montella, Heather Lipkind, Maternal obstructive sleep apnea and neonatal birth outcomes in a population based sample, Sleep Med. 2020 February ; 66: 233–240
- Yadav A, Beilin LJ, Huang RC, Vlaskovsky P, Newnham JP, White SW, Mori TA. The relationship between intrauterine foetal growth trajectories and blood pressure in young adults. J Hypertens. 2022 Mar 1;40(3):478-489.
- Chen Y-H, Kang J-H, Lin C-C, et al. Obstructive sleep apnea and the risk of adverse pregnancy outcomes. Am J Obstet Gynecol 2012; 206: 136.e1–136.e5.
- Pamidi S, Pinto LM, Marc I, et al. Maternal sleep-disordered breathing and adverse pregnancy outcomes: a systematic review and metaanalysis. Am J Obstet Gynecol 2014;210:p. 52 e1–52
- Faulsson, L., Arvini, S., Bergström, N. et al. The impact of premature birth on dental maturation in the permanent dentition. Clin Oral Invest 23, 855–861 (2019).
- Layza Rossatto Oppitz et al, Can preterm birth affect the palate morphology? A systematic review, Research, Society and Development, v. 10, n. 10, e107101018812, 2021
- Liselotte Paulsson, Bjorn Soderfeldt, Lars Bondemark, Malocclusion Traits and Orthodontic Treatment Needs in Prematurely Born Children, Angle Orthod (2008) 78 (5): 786–792.
- Blyton D M; Skilton M R; Edwards N; Hennessy A; Celermajer D S; Sullivan C E. Treatment of sleep disordered breathing reverses low fetal activity levels in preeclampsia. SLEEP 2013;36(1):15-21
- O’Brien LM. Positive airway pressure as a therapy for pre-eclampsia? SLEEP 2013;36(1):5-6
- Kahrilas PJ, Shi G. Why do we hiccup? Gut 1997;41:712-3.
- Jane Warland, Jillian Dorrian, Janna L. Morrison, Louise M. O’Brien, Maternal sleep during pregnancy and poor fetal outcomes: A scoping review of the literature with meta-analysis, Sleep Medicine Reviews 41 (2018)
- Aaron Laposky, PhD, Bictoria Pemberton, RNC, MS, CCRC, Sleep-Disordered Breathing and Pregnancy-Related Cardiovascular Disease, JOURNAL OF WOMEN’S HEALTH Volume 30, Number 2, 2021
- Dunietz GL, Hao W, Shedden K, et al. Maternal habitual snoring and blood pressure trajectories in pregnancy. J Clin Sleep Med. 2022;18(1):31–38.
- Edwards N, Blyton DM, Kirjavainen T, Kesby GJ, Sullivan CE. Nasal continuous positive airway pressure reduces sleep-induced blood pressure increments in preeclampsia. Am J Respir Crit Care Med 2000; 162:252–257.
- Blyton DM, Sullivan CE, Edwards N. Reduced nocturnal cardiac output associated with preeclampsia is minimized with the use of nocturnal nasal CPAP. Sleep 2004;27: 79–84
- ClinicalTrials.gov. Continuous positive airway pressure (CPAP) for sleep apnea in pregnancy (SLEEP) NCT03487185. 2018. Available at: https://clinicaltrials.gov/ct2/show/NCT03487185 Accessed June 24, 2020.