Welcome. I am Dr. Michelle Cantwell, and I'm moderator for this evening's webinar on Pregnancy and OSA, Risk to Mother and Child, and I'm joined with our speaker, Dr. Michelle Oken. If you are able to see and hear me right now, that means that you have successfully logged into the meeting. All participants' audio has been muted to ensure that all of us can hear clearly. If you're unable to see me, please try refreshing the browser. It may be possible that you need to refresh it several times. If refreshing your browser does not resolve the issue, click the link below the video that reads, connect directly to the webinar platform. This should connect you to the webinar via Zoom. However, you will need to return to the conference's IO platform if you'd like to use the Q&A feature. The platform that we're using for this webinar allows you to submit questions anonymously. 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Well, I want to welcome everyone this evening to this webinar presentation on obstructive sleep apnea and pregnancy. You have here my credentials and where I'm at. I'm in the Colorado Springs area right now, and we had our first snow today, so it's a little chilly, but of course tomorrow we'll probably be back in the 60s. But I want to thank you for joining me on this topic as it is near and dear to my heart. So the first thing that I want to address is conflict of interest. I have no potential conflicts of interest to disclose that relates to this talk. I have a handful of objectives that I hope that you take away from this talk today. One is to describe how and why more women are developing OSA in their childbearing years, to discuss the evidence as to what having OSA in pregnancy means both for maternal as well as infant outcomes. And then lastly, and I think importantly, is how healthcare providers such as yourselves may proactively facilitate an early identification of OSA and treatment options. So before I dive into some of the pregnancy aspects, I wanted to kind of lay a foundation for you and remind you or to just inform you in general that the prevalence of sleep disorders is actually quite different for men and women. Importantly, both sex and gender influence the way we sleep, how we perceive the importance of sleep and how we are affected by sleep. I wanted you to kind of take note of this picture here. And along the X axis, you see obstructive sleep apnea on the left, you see insomnia in the middle, and then you see your restless legs depicted on the right. And the bars show you men, women, and the male to female ratio as far as what we are currently aware of the values. So as you can see, women do not experience obstructive sleep apnea as much as men. And most of us are pretty consistent or we know that this variable is true. On the other hand, when you look at insomnia, women have almost a twofold increased risk for developing insomnia. And the same goes with restless legs. And even though I won't be talking about it too much, this is actually a result of a pregnancy where women tend to experience a significant increase in RLS in the third trimester. So there is growing evidence that on average, women in the United States get more total sleep. This ranges about maybe five to 28 minutes. This is by self-report. So take that with what you will. Women do experience more sleep fragmentation than men. They do report a lower quality of sleep. And some speculate that women have a greater sleep quantity. They spend more time in bed to compensate for that reduced sleep quality that they report. Again, there are sex and gender-based factors that influence how women and men sleep differently. And I'm going to address a couple of those. So I'm going to really talk about hormones in a little while as this is particularly relevant to pregnancy. The sleep cycles are different. And then of course, circadian rhythms. We know research has shown that women's circadian rhythms are actually a little shorter than men by a few minutes. But if you think about a few minutes adding up day after day after day, that can actually significantly alter their circadian rhythm. Their timer is a little earlier. So they have a tendency to fall asleep a little earlier and wake up a little earlier than men. And of course, these differences in sleep disorders start very early, usually during puberty or the onset of puberty, as well as we see significant difference when the onset of the menstrual cycle occurs. But keep in mind that both social and cultural patterns and norms may influence sleep at an even earlier age. If you think about how your parents taught you to sleep or how they informed you or if they treat both your siblings, if they're male or female, if they treat them differently, this can have an impact on lifelong sleep patterns. And of course, the differences in men and women is particularly true for obstructive sleep apnea. This cute visual shows a couple of the differences that are more prevalent in women, which are on the left there. And then, of course, those that are more prevalent in men on the right. It is well accepted that men have OSA more often than women. The rates can be anywhere from three to one to five to one in the general population. And in clinical settings, such as the sleep labs, this is actually much higher. The difference is less pronounced now as we kind of start to pay attention to the fact that women, especially at certain stages of life, will experience or be more at risk or susceptible to develop sleep apnea. And again, one of those that we're going to be talking about today is pregnancy. Another, of course, is the menopausal transition that increases the risk for women to develop disorder. So one reason for the discrepancy in the prevalence of the disorder is risk factors labeled here. And then I'll talk about clinical manifestations in the next slide. So some of the sex differences that we see between men and women include upper airway anatomy, as well as respiratory stability in OSA. And this can contribute to the difference between the two. So for instance, the upper airway in female patients are less collapsible and they're more stable during sleep than in male patients. And as a result of various complex mechanisms, including, you guessed it, sex hormones, this can have an impact on the prevalence and the diagnosis as well. There have been some MRI studies showing that the airway length, the tongue, the soft palate, and the total amount of soft tissue in the throat are smaller in women than in men. Again, increasing their risk for potentially not developing full-blown sleep apnea, but maybe upper airway resistance. So it appears that men have a longer, softer oropharynx, a larger, fatter, more posterior tongue. And this increases the susceptibility of the large airway to collapse. Now, most of these differences that we see, the sex differences are occurred during non-REM sleep. And this suggests that men may be more susceptible to pharyngeal collapse than women during established sleep rather than the sleep transition. There are a variety of disorders that we know also do increase the risk for developing OSA. Of course, congestive heart failure, type 2 diabetes, high blood pressure. But specifically for women here, polycystic ovarian syndrome and various hormonal disorders that occur primarily or only in women increase the risk for them to have obstructive sleep apnea. Now, the clinical presentation of OSA in women. This is very interesting and hopefully will open some eyes for some of the people listening to this. There are distinct differences in how women present the symptoms. So listed here on the slide here are a variety of symptoms that most women tend to present when they are actually experiencing obstructive sleep apnea. So they tend to present these non-specific symptoms. These might include insomnia, depressive symptoms, fatigue, possibly morning headaches, and even nightmares. Importantly, the tried and true symptoms regarding the reporting snoring, apneas, or excessive deep time sleepiness, which is what we initially think about when we think of obstructive sleep apnea. This is actually quite discordant in women. So these are typical of men, but we don't tend to see these as much in women who present with OSA. So a consequence of these atypical clinical presentation of symptoms is that females tend to be misdiagnosed or underdiagnosed due to the different reporting symptoms. And unfortunately, they wind up getting treated for other disorders or diseases such as depression, insomnia, hyperthyroidism, and unfortunately may not get diagnosed with OSA until much later in life when they start going through that menopausal transition, where they're a little bit older and their BMI is much more closely in line with men, so that it makes it a little bit more feasible or discernible that they may have OSA. Now, women may be more prone to upper airway resistance syndrome. This is a disruptive but less severe sleep disorder than sleep apnea. It is a disorder which women have when they still snoring and they have a collapsible airway, but they don't have these frank apneas, and they do not have the severe or the significant oxygen level drops that we see in obstructive sleep apnea. However, airway resistance is still associated with a significant number of awakenings and sleep fragmentation. I alluded earlier about REM sleep versus non-REM sleep. Women are actually more likely to have sleep apnea during REM sleep. And since REM sleep is on average about 20% of our sleep duration, this may mean that women have less total sleep or total number of apneas during the entire night, which is indicated and is borne out, as I will talk about in a minute, that most women with sleep apnea have much lower AHIs. But during REM sleep, the apneas do tend to be more severe, meaning that they have longer and greater associated significant drops in oxygen level. There's also a difference in how we collect fluid in our lower extremities. So when we recline at night, that fluid tends to shift to other areas in the body, which include the neck. And this shift, which accounts for a lot of the upper airway narrowing, differs between men and women. Men have greater narrowing of the airway, making diagnosis much easier. And then, of course, I want to, this is really, to me, this is quite important, is that there is a reluctance for women to actually acknowledge that they have symptoms of OSA and actually to seek medical help because it is long been thought of a male disease. So this may be more of a psychological barrier than a physiological one. In this picture here, I show you some risk factors that are very important to why women will develop OSA across various periods of their life. And so really what this picture is showing you, that the premenopausal state, so childbearing, postpartum, anytime before the premenopausal state, the woman is actually somewhat protected from the development of OSA. And as you can see, this is because she has a younger age. She has high levels of sex hormones, the estrogen and progesterone, as well as a different type of fat distribution than men. I call these the sirens for women because across the lifespan, both age hormones and fat distribution can be problematic, worrisome, and are really responsible for a lot of the sleep disorders as well as OSA that we see. So I'm going to discuss a little bit more about that in detail. Now, as far as hormones are concerned, all these sex hormones, estrogen, progesterone, and the androgens do play a role in the regulation of breathing. Estrogen increases the number and the sensitivity of progesterone receptors within the brain, specifically the hypothalamus and the medulla. These are the central neuronal respiratory related areas. And when we have an increase in estrogen during pregnancy, this allows the uterus and the placenta to basically increase vascularization, which is the formation of blood vessels, which allow transfer of nutrients to help support the developing baby. Now, in this slide, you see the effects of estrogen decline on sleep that tends to impact, again, menopausal women. But when we have appropriate levels and we see high levels that occur during pregnancy, there's an increase in REM sleep. This is important for mood, memory, and learning. Sleep latency, so the time it takes people to fall asleep, is decreased. Women experience fewer awakenings when there's an appropriate levels of estrogen. And estrogen also increases total sleep time. One of the important aspects across the women's lifespan, just not with pregnancy over the menopausal transition, is that estrogen is important for regulating body temperature during sleep. And it also helps regulate various neurotransmitters such as serotonin, which are important for controlling mood. And as you can see, when there is a decline in estrogen, this can cause disturbed breathing during the night. Again, it can increase the risk for sleep apnea. Now, progesterone is a really relevant and critical hormone as far as pregnancy is concerned because it increases the ventilatory responsiveness to hypoxia and hypercapnia. In fact, high levels of progesterone during pregnancy are responsible for the increased ventilation during this physiological state. And again, it's thought that these female hormones are quite protective against OSA due to their effect on the upper airway dilatory muscles. And fortunately, if any of you have been or you recall pregnant, people often breathe faster due to both the increase in progesterone and estrogen as progesterone in itself is a respiratory stimulant. So this hastens the breathing and we get more shallow breathing during pregnancy and also due to the diaphragm rising up. So I mentioned hormones as an important regulator as far as OSA is concerned, and probably the more critical one is body mass index. So there are definitely some significant differences, sex differences with regards to weight and BMI and its effect on OSA. Now, of course, people who are overweight and obese are more likely to have respiratory symptoms than individuals with a normal BMI. Most of us aren't aware of that. But for the same body mass index, males tend to have a higher upper airway fat distribution, which is important for the pathogenesis, which is why men may experience OSA more often than women. And then you have with increased overweight and obesity, you have an upper body and visceral adiposity that has been associated with reductions in lung function, including total lung capacity, forced vital capacity and forced expiratory volume. And then in addition to that, the effects of body fat distribution on lung function are more pronounced in men than they are in women. So in a nutshell, the lung volumes and capacities become larger with increasing BMI. Women are unfortunately when they are obese and they have OSA, they have a significantly increased hypercapnic and hypoxic responses, where this is actually not the case in men. So women actually have a worse interaction when they have the presence of obesity and OSA. And as I mentioned earlier, their AHI tends to be lower because they have most of their apneic events during the REM period. Now, the mechanical effects of obesity produce airway narrowing and closure and increased respiratory system resistance. So compared to healthy weight controls, the airway narrowing and obesity correlates with airway closure and airway hyper-responsiveness. So again, as we see, there's a lot of problems when you have obesity in the presence of some hormones when you have in the presence of pregnancy. So let's get into how pregnancy actually initiates impacts and can increase OSA. So for most women, the experience of pregnancy should be a joyous occasion, but when any or all of those previous physiological influences accompany the pregnancy, she may become extremely susceptible to various sleep disorders and in particular obstructive sleep apnea. According to some of the data, about 20% of women are currently struggling with obstructive sleep apnea and oftentimes they don't even know. And this will come into a discussion in a little while. So how does pregnancy set off? How does it influence and or escalate the risk of OSA? And what are some of the deleterious outcomes that can result? So as I get into that, I just wanna first kind of orient you to some suggestions from some researchers, Dominguez and her colleagues suggest that there are two distinct clinical phenotypes of OSA in pregnancy. The first one being women with preexisting OSA who then become pregnant and may experience a worsening of their condition. So that's the first one. And then women who develop OSA related to weight gain and or airway or respiratory changes due to pregnancy or the hypertensive disorders of pregnancy. It's thought that the first one, again, entering pregnancy with OSA is the more problematic and linked to more pregnancy outcomes. A myriad of physiological changes occur when a woman becomes pregnant. And a lot of these do significantly increase the risk for developing obstructive sleep apnea. There are changes in the cardiovascular, the respiratory, hormonal, immune changes. There's obviously a significant increase in maternal fat, blood volume, cardiac output, and blood flow to the kidneys and utero placental unit. And finally, a decrease in blood pressure. Yes, there is a decrease in blood pressure that should occur. The first and most obvious change in pregnancy is weight gain. So there is a typical 20% increase that is expected or that is seen in body weight when a woman becomes pregnant. And of course, if she is already overweight or obese, this can tip the scales for increased morbidity, both for her and for her baby. So the presence of obesity itself in pregnancy is associated with several vascular complications such as hypertension and obstructive complications such as prolonged labor and an increased risk of postpartum hemorrhage and vaginal deliveries. So in addition to the weight gain and those issues, there is also an increase in uterine volume which elevates the diaphragm leading to impairments in respiration. You can see that on the picture just above the baby where it says elevation of diaphragm. You also have upper airway remodeling and edema during pregnancy. And these are similarly associated with changes in oncotic pressure. And again, along with functional residual capacity, chest wall compliance, these may increase the risk of a pregnant woman developing OSA or having it worsen across time. So as shown in the visual, the pregnant woman has a narrowing of the oral pharynx. This leads to a more nasal congestion caused by increased blood flow and an increase in estrogen. And this leads to an increase in hyperventilation. All of these, as if that isn't enough, all of these are associated with susceptibility to obstructive sleep apnea during pregnancy. They also experience changes in the oral pharyngeal diameter. They have increased mom potty score as well as increased oxygen consumption. But all is not bad, all is not for worse here. There are some protective changes to note that by sleeping in the lateral sleep position, this often can alleviate some of the issues. And of course, progesterone, one of its primary goals, as I mentioned, is to increase respiratory rate. So that keeps the breathing perpetual and continual. Some of the data about OSA in pregnancy suggests that about a third of women do snore by the third trimester. And I'm not sure if that is clinically accurate. I believe that as, especially in obese women, that number is actually quite high. About 15 to 20% have OSA. And OSA in pregnancy is likely underdiagnosed, as I mentioned, due to, I'll talk about lack of validated screening tools, insufficient provider awareness, and a greater need for all of us to have a better understanding of the dynamic effects of pregnancy on OSA. Recognizing the importance of overweight and obesity for pregnancy outcomes. Nationwide, it is estimated that 47.5% of women had excessive weight gain during their pregnancies. Now, as you can see from the picture on the left there, this is suggested by ACOG, which is the American College of Obstetricians and Gynecologists, the appropriate amount of weight gain that a woman should gain when she is pregnant. So if she starts underweight, she would suggest gaining anywhere from 28 to 40 pounds. But if she is already entering the pregnancy obese, it is only 11 to 20 pounds. And while I have not been pregnant, I know many pregnant women will say that they put on 40 to 60 pounds in their pregnancy. So we know that a lot of women will have excessive, above recommended weight gain in their pregnancy. Now, excessive weight gain is a problem for women across the entire BMI spectrum. Among those who are underweight, 23.5% who start their pregnancy underweight will wind up having an excessive weight gain, especially 37.5% of those normal weight before they got pregnant had excessive weight gain. But it is especially rampant among women who are overweight or obese. The numbers are about 62% and about 56% of them respectively. So overweight and obese added too many extra pounds during that nine months of pregnancy. So as you can see on the right graphic, maternal obesity can increase the risk of several pregnancy complications that are known to be harmful to mother and or baby. And I'll mention these in the next few slides. But for obese women, it has been suggested or it's been shown that OSA development actually occurs in the earlier stages of pregnancy compared to normal weight who actually develop in the third trimester. So this is a significant problem because of the longitudinal impact that obstructive sleep apnea can have on the health of the mother across the entire gestational period rather than the latter third trimester. Now in a pregnant population with a BMI above 30, it has been reported that the prevalence of mild, moderate and severe cases of OSA in the first trimester were 21%, six and 3% respectively. And then this increased up to the third trimester to 35, seven and 5%. So really we see a lot of mild sleep apnea across pregnancy in women with a BMI above 30. And then other studies have reported the prevalence of OSA in obese women to be as high as 43%, as well as 50%, again, depending on the population study. And one study found that compared to lean women and overweight women, obese and overweight women were 4.69 and 13.23 fold higher risk of OSA and developing OSA respectively. So as you can see, it really can impact the development of OSA when you enter a pregnancy already obese. And if that wasn't enough, OSA disproportionately affects women of low socioeconomic status, as well as those who self identify as black. So as the majority of OSA cases may occur in the third trimester, it is likely that those who are obese when they enter pregnancy will have an earlier onset of gestational OSA. And this is often again overlooked or misdiagnosed or left untreated. And this can lead to greater morbidity in both mom and baby by the time the baby is delivered. This is just to kind of indicate and show you the various hormonal changes across pregnancy. You see the blue of estrogen and the red of progesterone that they significantly increase across pregnancy and hit their peak right at delivery. They have been shown to also contribute to sleep disturbances, especially when they hit their peak in the third trimester. There is some suggestion that the elevation or a higher elevation of estrogen and progesterone may be associated with the more severe phenotype of OSA, especially in the later stages of pregnancy. And indeed one study found that progesterone levels after accounting for weight and gestational age were lower in women with OSA than controls. And remember progesterone increases ventilatory drive and response, and that not having that ventilatory drive can increase the risk for OSA. So progesterone, again, plays a protective role against the development of OSA. This is another graphic that I wanted to kind of show you the difference between estrogen and progesterone and how these hormonal changes can affect women who are already obese in pregnancy to develop OSA. So in addition to what you see in the figure above, estrogen also causes vasodilation, so the vessels to widen, so you have more blood flowing through. And this may lead to swelling or edema, not only in the feet or legs, but also in the neck and the nasal area leading to nasal congestion and rhinitis, which of course we know can disrupt sleep and lead to upper airway resistance. Likewise, progesterone relaxes smooth muscle and may contribute to also nasal congestion. Again, these all are disruptive of sleep and they all are prodromal symptoms to the development of obstructive sleep apnea. So as you can see here, both estrogen and progesterone downstream, whether they increased respiratory stimulation or increased nasal congestion lead to upper airway negative pressure, diaphragmatic drive and upper airway resistance leading to more snoring and major oxygen desaturation during pregnancy. Several investigators have labeled the time of pregnancy and the sleep that occurs as a pregnancy-related sleep disorder, because a lot of the issues that women will complain of, whether it's insomnia or whether it's sleep disorder, breathing and snoring are initiated and start when a woman becomes pregnant. So the sleep disorder breathing can range from mild snoring at one end to overt OSA at the other end. And the obstruction of the airway leads to reductions in airflow, obviously, and that leads to hypoxemia, activation of the sympathetic nervous system, and then a significant increase in awakenings. And what's interesting is data from the National Sleep Foundation about almost 10 years ago reported, again, this was a phone call self-report that about 80% of pregnant women had sleep alterations or sleep disorders that were actually not present before pregnancy. So again, pregnancy can initiate and establish the foundation by which either OSA, insomnia, or other sleep disorders can develop. But more recently, Judette Lewis, she estimated that sleep deficiencies occur in about maybe 10 to 32% of pregnancies. And this wide range, if you're thinking, wow, this is a very wide range of women who are complaining of sleep disorders, the inconsistencies, the misinformation for clinicians is a major problem. So the screening protocols are inconsistent, and I'm gonna talk about that in a little bit, as well as the diagnostic criteria are very inconsistent across time. So that's why the numbers are so variable. The physiological consequences of OSA are pretty significant. And again, I will highlight this later about the identification and the treatment. It's really important to identify as early as possible because when a woman has obstructive sleep apnea, and again, whether or not she is obese, if you add obesity on top of this, you're actually exacerbating the problem. So you see on the left with sleep apnea, there is intermittent hypoxia and re-oxygenation. This has a significant impact on the placenta, which I'll talk about in a little bit. Then you have those frequent arousals from sleep due to obviously not having enough oxygen. Both of these lead to an increase in oxidative stress. An increase in inflammation, an increase in endothelial dysfunction, and an increase in sympathetic activation. And so one potential outcome is an increase in insulin resistance, which we know is a precursor to diabetes. So in pregnancy, the case would be gestational diabetes. And then there's also hypertension, which can concomitantly lead to hypertensive disorders of pregnancy. And one of the fascinating things, pregnancy alone, just normal pregnancy, increases the risk for future cardiovascular disease in women. Not quite sure of the pathways to that, but the evidence is pretty solid on that. And so if you add OSA and or obesity onto that platform, you see a potential just exponential increased risk for cardiovascular disease later in life. There are a host of dangers that are associated with sleep apnea during pregnancy. The increased BMI, preterm labor and delivery, obviously, gestational diabetes and hypertension, which I talked about, preeclampsia. I'm gonna talk about that in the next slide. So we know that OSA has quite a few serious implications for the health of mothers. But a couple that I want to talk about a little bit more that are ones not listed on here is placental development. As I mentioned in that previous slide, maternal obstructive sleep apnea has been found to be associated with increased placental weight. This is the placental weight is correlated with OSA severity and neonatal adiposity. And this is actually independent of the BMI of the mother. To kind of explain this a little bit more, a greater placental weight often results in a decreased fetal-placental ratio, which is used as a proxy for placental efficiency. So in layman's terms, not in OB-GYN terms, a reduction in this fetal-placental ratio suggests potentially an impaired nutrient transport ability of the placenta, which can influence the development and create negative obstetric outcomes. So the baby will not get the nutrients that it needs. So that is one major consequence of sleep apnea during pregnancy. Another is depression. And I think this may get overlooked often because we look at gestational diabetes and hypertension, but OSA increases the levels of depression potentially twofold. One is a result of the self-reported sleep disturbances, the inadequate sleep or excessive daytime sleepiness and fatigue that a woman may report. So she may subjectively report these sleep disturbances. In addition, we know that obstructive sleep apnea is associated with increased inflammation. Inflammation is associated with an increase of experience of depressive symptomatology. So you may have a twofold impact from OSA on the increased risk or potential of depression during pregnancy. And this being my primary area of work, the negative outcomes of a woman experienced perinatal depression can have significant long-term impacts on the infant, as well as the mom herself. And we know that in the presence, there is an interaction found between OSA and history of depression, specifically in women with no depression. With OSA, they get some depression, but if you have OSA, the depressive symptoms are significantly increased in these women. Here's one example I wanted to share with you about how OSA can increase the risk of preeclampsia. As dental professionals, you may be able to detect OSA early in pregnancy, which could help with the prevention of adverse outcomes. So preeclampsia is defined as a rapidly progressive condition characterized by high blood pressure. Again, women's blood pressure should lower in pregnancy because of the vasodilation. And there's usually protein in the urine. And when these women experience very high blood pressure, this has impact on the blood vessels, causes them to contract and have impact on a variety of organs in the body, as you can see from this picture. While this does not sound very catastrophic or very bad initially, just saying hypertension, it could be catastrophic for both mom and baby. The OSA increases hypertension, and we know that 5% of these can result, of pregnancies can be preeclampsia. And the outcome for the mom could potentially be death because she may experience major seizures and potentially die. And the only cure for preeclampsia is actually to deliver. So we never want to see a woman have eclampsia. The other one I want to highlight here is how OSA can increase the risk of gestational diabetes. Again, obstructously, bapnea is linked with episodic hypoxia, which increases inflammation simultaneously with sympathetic activation. That episodic hypoxia leads to a decrease in adiponectin, and along with inflammation, can increase the risk for insulin resistance. And then the sympathetic activation is associated with an increased risk in cortisol. Again, both contributing to an increased risk in gestational diabetes. And GDM actually occurs in about two to 10% of all pregnancies in the United States. So it's fairly common. What about impacts on the fetus? Chronic sleep disturbance, nocturnal hypoxemia, as well as neuroendocrine alterations that are associated with obstructive sleep apnea may indeed affect fetal growth and wellbeing. And this can include fetal heart rate abnormalities, as well as fetal growth restriction. Gada Bourjeli and her colleagues have reported that obstructive sleep apnea is associated with a higher risk of several congenital abnormalities, including musculoskeletal, ophthalmologic, gastrointestinal, as well as circulatory abnormalities. And if a mom has OSA, there is a one and a half to twofold increased risk of having a low birth weight baby or a small for gestational age infant. So there are some significant effects that we can see that have been associated, but there's a lot to still be looked at as far as these associations. I wanna switch to talking about identification of OSA in pregnancy. There are a variety of symptoms that should signal the health provider to inquire further and possibly refer to a specialist if you are not one. There are a variety of questionnaires listed there under those screening tools that I know actually do not get incorporated into maybe the initial paperwork in a clinic, but they would actually be very helpful. And then you can easily, based on that, refer out to a clinician. So screening in pregnancy suffers even more than I previously discussed. There's a very large false positive and a referral rate for PSG, but maternity care providers, dental, sleep medicine, any kind of primary care can help identify or potentially refer a woman out if they see these signs and symptoms. You see on the left, if the BMI is greater than 30 or 35, the neck circumference is greater than 16 inches. She complains that she's snoring, consistent chronic hypertension over time, morning headaches, and of course, if there's witnessed apnea, those are the chronic classical symptoms. And then you would refer for evaluation and diagnosis, potentially PSG, which is of course the gold standard. And home sleep testing has become much better at identifying sleep apnea, especially in pregnant women. There've been quite a few that have been validated in pregnant women. Unfortunately, there are no pregnancy-specific guidelines for the detection or management of obstructive sleep apnea. So we're still kind of waiting on that. OSA is an underdiagnosed, underappreciated condition in pregnancy. And this decision tree, I know it's a little small, but really, if you can make it bigger, but it comes from 2009, so it's actually quite old. And the suggestion is to evaluate them, see if they have excessive daytime sleepiness, gasping and choking. The typical, the traditional clinical symptoms that we know are much more common in men. And so by only looking at those, you often get a false negative in that the women may actually have OSA and then there's no referral. So the overnight in-lap sleep, PSG, can be expensive. There's often backlogs to get these done. The clinics are backed up for months. We can do the HST. It's much more reliable these days, much more convenient and cost-effective. And again, this decision tree is from 2009 and not much has really changed since then. And some clinicians will have suggested that, and I'm quite big of agreement, that all obstetric patients should be assessed for OSA, especially to screen for new onset or if there is a medical history of SDV or OSA. So again, identifying some of these symptoms, especially the non-traditional symptoms and then refer them for a sleep study. So again, there's no current protocol for identifying OSA in pregnancy. You can see here on this slide, a variety of combination of factors that have been suggested to be better at identifying, better predictive of OSA in pregnant women. The questionnaires, the Berlin, the StopBang, even the EFRA sleepiness, they have very poor predictive value in pregnancy. Lewis and her colleagues suggested looking at age, body mass, and frequent snoring as the most important risk factors. Others have looked at self-reported snoring via mind tiredness at awakening, looking at tongue enlargement and looking at chronic hypertension. So as you can see, there's no consistency and no specific protocol for identifying pregnancy for OSA in pregnancy. And treatment, of course, will depend on the severity of the sleep apnea once it's actually diagnosed. And the symptoms. There are some easy ways that have been suggested. The adhesive breathing strips on the nose, saline rinses, making sure that your room has sufficient humidity in it. As someone who lives in Colorado, I can speak to the clinical relevance of that. Using over-the-counter decongestants or even dietary changes. These are easy ways and often do not really see any significant improvement in the symptoms of OSA. The best ways are to use a CPAP or BiPAP machines once the person is diagnosed. Oral devices, oral appliances are an excellent way to reduce snoring, especially pregnant women will have mild, as I showed you from the data, have mild sleep apnea. And so oral devices may be an ideal treatment option for these women. Nerve stimulation, the Inspire device has been, that's one of the things that's come out to stimulate the epiglottis. And then positional therapies. There's also myofunctional therapy, which consists of mouth and throat exercises that has shown to be associated with some reduction in daytime sleepiness and may increase sleep quality in the short term. But really none of these are really great options for pregnant women. This here is just from Judette Lewis and her colleague, Dr. Street, suggested management approaches after OSA has actually been diagnosed in pregnancy and the management across the peripartum period. So they indicate a multidisciplinary approach when managing a woman with OSA and that they should be followed into the postpartum period and that you should have a sleep medicine specialist along with the OB-GYN. And then if there is a need for surgery, such as a C-section or other types of surgical procedures due to the obstructive sleep apnea and or the obesity, again, keeping in mind that you need multiple disciplines, anesthesiology, because this is going to impact the ability to have a good surgery. So again, this is some suggestive stuff, but while there is no definitive method of identifying, there's no consistent treatment or protocol in what should be done when a woman actually is diagnosed with sleep apnea. So in summary, I want to remind you that women are more prone to developing sleep apnea at certain times of their life. And that is obviously during childbearing years when she's pregnant, as well as during the menopausal transition. And this is most likely the result of hormones and weight gain among potential other factors such as genetics and heredity. Pregnancy increases the chances of developing OSA due to all the ventilatory, respiratory, cardiovascular changes, hormonal changes that take place. And if a woman is obese, this increases the severity of OSA. If she already has a diagnosis of it. And of course, OSA is associated with significant maternal and infant morbidity. The diagnosis, again, I want to highlight that the diagnosis is very poor. It's very inconsistent by healthcare providers. Most OB-GYNs are just not aware. They just assume that it's waking and it doesn't have much of an impact. And the breathing is just kind of a side note of what happens in obese pregnancies. The treatment options are insufficient at this time and need much more evaluation, much more application that can be utilized and revised for pregnant women. And probably the last thing that I want to highlight for this particular audience is the area of dental sleep medicine, I believe is an excellent source for identification, treatment of OSA in pregnancy by using the oral appliances. And again, you see them and you might be able to identify this risk and identify these factors long before it becomes a significant problem. So with that, I want to thank you for your attention and I'm going to return it back to Dr. Cantwell. Thank you so much, Dr. Oken. And now for our audience, if any audience member has a question for our speaker and you're using the full screen mode, remember you need to exit the full screen mode to access the ask button to submit the question. I'm going to be going through the questions that have been entered from the top down. So please also make sure to use the upvote feature to move your favorite questions up to the top. And also in some instances, your question may be answered by the moderator in writing, in which case you're going to see a notice under the question with the phrase, tap to see the moderator's answer. So now let's take a look at some of the questions. First we have, if a patient is concerned about sleep apnea, when should a woman get tested? I'm assuming during pregnancy. So, like I said, there's no consistent protocol, but hopefully as women get more informed about some of the risk factors that they may be experiencing anytime. And if a woman is significantly overweight or obese and she has a lot of these risk factors, such as the snoring or the headaches or the insomnia or even more depression, this is a, in my opinion, a prompt for that person to inquire about getting a sleep study that can again be in the first, second, third trimester. It's not standard protocol to have pregnant women get sleep studies, unfortunately. I think they all should because you can even have sleep apnea, even if you're not putting on too much weight, you can have that impact on the diaphragm and the respiratory system. And next we have the question, how many women may have OSA before they are pregnant? So that's a great question. The estimates of women in their childbearing years who have OSA is fairly low. Most of the data, when you look at OSA across time in women, they combine postmenopause, menopausal transition and then childbearing. So it's often actually very low out if there's no obesity. When there's obesity present, that number jumps up significantly. So if you have to kind of tease apart whether a person, a woman is obese or overweight and then in childbearing years, the estrogens and progesterone really prevent, they're very preventative to the development of OSA prior to the menopausal transition. Next question, if a woman does not have sleep apnea before she's pregnant, is there a direct correlation between oral structures, i.e. melampotis score and the risk for sleep apnea or is the relationship more about weight gain or more to the weight gain? That's a great question. So I know, I know Gada Borgelli, they've been looking a lot at the melampotis score and in all the stuff that I'm, that I read as far as OSA or co-morbid with insomnia, the melampotis score, so the structure seems to be much more or is gaining more relevance as far as needing that to identify OSA. So I don't know if you can, if I am not that much of an expert on it, can actually say that one is more important than the other. I think it's easy to place the blame on weight gain right now, but I think as we start to look at more of these risk factors that the melampotis score is becoming much more prevalent as a risk factor, I think things will start to balance out and we'll realize that they're both actually contributing maybe fairly equally, maybe one more than the other, but it's hard to say at this stage in the game. Thank you. Next question, is the rate of obstructive sleep apnea in pregnancy in the US higher than in other countries? From what I've read, yes, it is significantly higher because we have greater rates of overweight and obesity, but that does not suggest that there are no cases of OSA because we know that even in Asia, women who have much lower BMIs, they still tend to have obstructive sleep apnea, just not at the rates that we see in the US, but it is consistently seen all over the globe. If a woman plans to get pregnant, shouldn't she be screened and tested as indicated before becoming pregnant? I think so. I'm a big proponent of having sleep studies, screening as preventative healthcare across the lifespan. I believe that kids need to be screened, kind of like we do with everything else, we get preventative screening. I think having a sleep study done maybe every five years or so, if not more, might be a great way to identify early in children and teenagers and pregnant women or pre-pregnant women, whether they are at risk or they are experiencing mild sleep apnea, which would intensify during the state of pregnancy. So I think, yes, that would be a nice thing. It's just, can we get insurance and providers on board? If a patient develops sleep apnea during pregnancy, will it resolve after delivery? Great question. So yes, a lot of the sleep apnea will, that initiated during pregnancy. So if she had obstructive sleep apnea before pregnancy, that's gonna most likely continue. But those who have OSA that develops in pregnancy often goes away once the woman delivers and loses that excess weight. If there is still significant weight gain, if there's weight gain that stays or she puts on more weight in the postpartum period, that can perpetuate and continue the OSA. Good question. Given how innocuous treatment a well-made mandibular advancement device is for obstructive sleep apnea or snoring, should the medical community consider empiric use of the mandibular advancement device therapy? And I presume you're saying in pregnancy. Yeah, so I don't know of any empirical studies. I have, I'm actually toying around with that idea with some of my colleagues in the area to do, I'm really interested to see if that would actually help reduce snoring and potentially the increase in weight gain that we see due to that. So I believe that we should empirically study that as an excellent alternative or as an excellent option, not even as an alternative, but an option for snoring during pregnancy. And then we're coming down to the end of our time. So we've got one more question. Are women who are pregnant and then need a mouth appliance actually able to tolerate it when they're pregnant if they've never had one before? And they're alluding to many women they feel get more gaggy during pregnancy. I have not seen, I did not come across any data that evaluated the tolerability, the feasibility, the acceptability of devices during pregnancy. I think this is really early on in the trajectory of where these can go. And I've heard quite a few people will say that they get more of a gag reflex and they can't handle, they still feel claustrophobic when they have them in. I have not seen any data nor have I heard any anecdotal data from my colleagues as to whether pregnant women can tolerate it more because of the enlargement in the neck area and the swelling, the edema they experience. But that's definitely something worth evaluating and assessing.

pregnancy

obstructive sleep apnea

OSA

hormonal changes

respiratory stability

weight gain

physiological changes

gestational diabetes

preeclampsia