Sleep Disorders in Pregnancy Linked to Adverse Outcomes

Research published in JAMA Network Open suggests that having insomnia or obstructive sleep apnea (OSA) during pregnancy may increase the risk of ischemic placental disease (IPD), severe morbidity, and preterm birth. IPD is a triad of placentally mediated complications that includes fetal growth restriction, or its commonly used surrogate, small for gestational age (SGA) birth; placental abruption; and hypertensive disorders of pregnancy.

“Most pregnancy research on sleep disorders has focused on obstructive sleep apnea. Our study shows that insomnia also deserves attention as a potentially important marker of obstetric risk,” says senior author Justin S. Brandt, MD, director of NYU Langone Health’s Division of Maternal–Fetal Medicine and Maternal–Fetal Medicine Fellowship.

“Our findings emphasize the importance of identifying best practices around screening and treatment for insomnia,” adds co-author and sleep medicine specialist R. Nisha Aurora, MD, MHS, director of women’s sleep initiatives in the Division of Pulmonology, Critical Care and Sleep Medicine. “Insomnia may be a potentially modifiable risk factor for obstetric complications.”

Dr. Aurora and Laura Jelliffe-Pawlowski, PhD, the Florence S. and William H. Downs Professor in Nursing Research, along with maternal-fetal medicine fellow Naima Ross-Pierre, MD, were co-investigators on the study with Dr. Brandt.

The Impact of Sleep Disorders

To investigate the associations between insomnia and risk of IPD and severe morbidity, and to compare the magnitude of this risk with that associated with OSA, the researchers conducted a population-based cross-sectional study of singleton live births in California.

Insomnia during pregnancy has been associated with preterm birth and is a well-established risk factor for perinatal mood disorders. OSA has likewise been associated with preterm birth, as well as severe morbidity and IPD, and with other pregnancy complications, including preeclampsia, gestational diabetes, and perinatal depression.

“Sleep may represent an overlooked and potentially modifiable component of prenatal health. The next step is to determine whether identifying and treating sleep disorders can improve pregnancy outcomes,” explains Dr. Brandt.

Shedding Light on the Risk

The analysis included over 4 million pregnant patients with singleton live births. Among the study cohort, the prevalence of insomnia and OSA was 116 and 136 cases per 1,000 live births, respectively.

The researchers found that pregnant patients with OSA had a 57 percent higher risk of IPD, a 181 percent higher risk of severe morbidity, and a 73 percent higher risk of preterm birth compared to patients without either OSA or insomnia.

Importantly, findings for pregnant patients with insomnia were similar. These patients were found to have a 42 percent higher risk of IPD, a 126 percent higher risk of severe morbidity, and an 81 percent higher risk of preterm birth compared to patients without either insomnia or OSA.

Another notable finding was that insomnia, but not OSA, was associated with a higher risk of birth of an SGA neonate, at 23 percent.

“The associations between insomnia and birth of an SGA neonate and some other placentally mediated complications suggests that additional fetal monitoring should be considered in pregnancies complicated by insomnia,” the authors write.

Future Investigations

In light of these findings, the researchers are now working to understand the mechanisms that underlie the association between poor sleep and placentally mediated complications.

According to the researchers, these data suggest overlapping but unique risk profiles associated with insomnia and OSA. However, further investigations are needed to characterize the mechanisms that underlie obstetric risk.

“We now need prospective studies to determine whether insomnia is simply a marker of increased obstetric risk or whether effective treatment can meaningfully improve pregnancy outcomes,” says Dr. Brandt.