Biology:Pregnancy and sleep

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Sleep during pregnancy can be influenced by various physiological, hormonal, and psychological factors, leading to changes in sleep duration and quality.[1][2][3][4] Furthermore, pregnant persons are more prone to experiencing sleep disorders like insomnia,[5] sleep-disordered breathing,[6] and restless legs syndrome.[7][8][9] Most women experience sleep disturbances during pregnancy.[10] Interrupted sleep is recognized for its substantial impact on health and its association with a heightened risk of unfavorable pregnancy outcomes.[1]

Aetiology

Anatomic and metabolic changes

Pregnancy brings about significant and dynamic physiological changes that can impact sleep and contribute to sleep disorders. These changes encompass structural alterations that may affect the length and quality of sleep, disrupt breathing during sleep, and metabolic shifts that raise the risk of restless legs syndrome. For example, conditions like gastroesophageal reflux tend to worsen as pregnancy advances, affecting a substantial portion of pregnant individuals and potentially causing sleep disruptions.[11] Frequent nighttime urination due to increased sodium excretion can also fragment sleep.[12] Additionally, the musculoskeletal system undergoes stress as it readies itself for the expanding uterus and eventual delivery, which can lead to sleep disturbances.[13] Alterations in iron and folate metabolism during pregnancy have been proposed as factors contributing to the higher prevalence of restless legs syndrome among expectant mothers.[1][14][15]

Hormones

The secretion of sex hormones like estrogen and progesterone increases significantly during pregnancy, influencing the regulation of sleep in terms of both circadian rhythms and sleep need.[1][16] Sleep disruption can also occur due to nighttime uterine contractions, which are a result of the nighttime surge in oxytocin levels.[1][17]

Sleep disorders

Sleep disorders are frequently experienced during pregnancy, impacting over 50% of all pregnancies.[18] These issues tend to become more prevalent as pregnancy advances. The most commonly observed sleep disorders in pregnant women include insomnia, obstructive sleep apnea, and restless legs syndrome.[18] The American Academy of Sleep Medicine has officially recognized 'pregnancy-associated sleep disorder' as a distinct condition, encompassing both insomnia and increased daytime sleepiness occurring during pregnancy.[19][20]

Parasomnias

Parasomnias represent a notable concern in pregnancy, with somnambulism, nightmares, night terrors, and vivid dreams being frequent occurrences.[9][21] The disrupted sleep experienced during pregnancy, along with sleep disorders like sleep-disordered breathing and movement disorders, can act as substantial triggers for parasomnias, leading to an elevated likelihood of experiencing such episodes during pregnancy.[9]

Insomnia

Pregnancy-related insomnia is quite common.[22] As pregnancy advances, both subjective and objective assessments reveal a notable increase in sleep disruptions.[5][23][24][25] Researchers who have used polysomnography to study sleep in pregnant women have observed distinct patterns. These patterns include more wakefulness after initially falling asleep, reduced rapid eye movement sleep, and a greater amount of time spent in lighter sleep stages compared to non-pregnant women.[5][26][27] Furthermore, as pregnancy progresses, women tend to experience less total sleep time, increased wakefulness after falling asleep, more time in lighter sleep stages, decreased periods of deep and rapid eye movement sleep, and more frequent awakenings compared to earlier stages of pregnancy.[23][28] Additionally, it's common for pregnant persons to express dissatisfaction with the quality of their sleep, with almost half reporting poor subjective sleep experiences.[4]

Restless legs syndrome

Restless legs syndrome is a condition characterized by uncomfortable sensations in the legs and an irresistible urge to move them, particularly during periods of rest or inactivity.

The condition is more common among pregnant women than in the general population.[7] Research studies have reported varying prevalence rates, with estimates ranging from 10% to 34% of pregnant individuals experiencing RLS symptoms at some point during their pregnancy.[29]

Sleep-disordered breathing

Snoring and sleep-disordered breathing are significantly more common in pregnant women, being 2–3 times more prevalent than in nonpregnant females.[30] These changes are associated with alterations in upper airway anatomy and tend to return to nonpregnant levels after childbirth.[30]

Obstructive sleep apnea is a condition where breathing repeatedly stops during sleep due to the collapse of the upper airway, often leading to a decrease in oxygen levels. It is a prevalent health concern among pregnant women and is linked to various pregnancy-related health consequences.[6][31] The condition is more prevalent in pregnant women who are obese.[32][33] Pregnancies where obstructive sleep apnea is a complicating factor face a higher risk of developing conditions like intrauterine growth restriction, pre-eclampsia, and stillbirth.[32]

Management

The management of sleep disorders during pregnancy may require the use of psychopharmacological drugs.[34] Primary insomnia can be managed with cognitive behavioral therapy and medication, while secondary insomnia should primarily target the underlying medical issue.[35] When dealing with restless legs syndrome, treatment includes medication use and minimizing exposure to triggers like smoking, caffeine, and specific medications.[35]

Sleeping positions

The National Health Service (NHS) advises pregnant individuals to sleep on their side, either the left or right, for optimal safety during pregnancy.[36] Research indicates that beyond the 28th week, assuming a supine (back) sleeping position can result in a twofold increase in the risk of stillbirth.[36] This increased risk may be attributed to potential disruptions in fetal blood circulation and oxygen supply.[36] Sleeping on the back can also give rise to various complications, including back pain, respiratory issues, hemorrhoidal problems, low blood pressure, gastrointestinal discomfort, and reduced blood flow to both the maternal heart and the developing fetus.[37] Furthermore, the weight gain associated with pregnancy may heighten the likelihood of developing sleep apnea when sleeping on the back.[37]

Dreams

During pregnancy, a significant period of emotional adjustment occurs, involving thoughts, feelings, and relationships regarding oneself and the unborn child, which often find expression in dreams. Pregnant women often describe their dreams as exceptionally vivid and realistic.[38] Some systematic studies suggest that the majority of pregnant women (67–88%) report experiencing at least one dream related to topics like pregnancy, childbirth, or babies.[39][40][41][42] Additionally, some other studies indicate that 30–62% of these dreams include maternal elements, and their frequency tends to increase as pregnancy progresses.[39][43][44][45][41] These dreams typically touch upon the mother's physical well-being and the baby's sex, but may also feature elements of danger or harm to the baby, mother, father, as well as issues within the family and marriage.[39] Pregnant individuals tend to have better dream recall, and notably, the content of their dreams tends to be more disturbing compared to other life stages.[10][38][46] Comparative research suggests that pregnant persons recall more dreams centered around pregnancy-related themes (e.g., childbirth, pregnancy, the fetus, their own body, the baby's body) and more elements involving potential risks to the fetus and themselves.[39][47][42] Pregnancy can influence dream patterns, leading to an increased likelihood of experiencing bad dreams and nightmares.[10] Pregnant women's dreams tend to be more masochistic and include more elements where they experience misfortune, harm, or face environmental threats, although they do not necessarily involve more aggressive actions.[39]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Pengo, Martino F.; Won, Christine H.; Bourjeily, Ghada (2018). "Sleep in Women Across the Life Span". Chest (Elsevier BV) 154 (1): 196–206. doi:10.1016/j.chest.2018.04.005. ISSN 0012-3692. PMID 29679598. 
  2. ↑ Cai, Shirong; Tan, Sara; Gluckman, Peter D.; Godfrey, Keith M.; Saw, Seang-Mei; Teoh, Oon Hoe; Chong, Yap-Seng; Meaney, Michael J. et al. (2016-12-09). "Sleep Quality and Nocturnal Sleep Duration in Pregnancy and Risk of Gestational Diabetes Mellitus". Sleep (Oxford University Press (OUP)) 40 (2). doi:10.1093/sleep/zsw058. ISSN 0161-8105. PMID 28364489. 
  3. ↑ Meers, Jessica M.; Nowakowski, Sara (2022-06-11). "Sleep During Pregnancy". Current Psychiatry Reports (Springer Science and Business Media LLC) 24 (8): 353–357. doi:10.1007/s11920-022-01343-2. ISSN 1523-3812. PMID 35689720. 
  4. ↑ 4.0 4.1 Sedov, Ivan D.; Cameron, Emily E.; Madigan, Sheri; Tomfohr-Madsen, Lianne M. (2018). "Sleep quality during pregnancy: A meta-analysis". Sleep Medicine Reviews (Elsevier BV) 38: 168–176. doi:10.1016/j.smrv.2017.06.005. ISSN 1087-0792. PMID 28866020. 
  5. ↑ 5.0 5.1 5.2 Sedov, Ivan D.; Anderson, Nina J.; Dhillon, Ashley K.; Tomfohr-Madsen, Lianne M. (2020-11-02). "Insomnia symptoms during pregnancy: A meta-analysis". Journal of Sleep Research (Wiley) 30 (1): e13207. doi:10.1111/jsr.13207. ISSN 0962-1105. PMID 33140514. 
  6. ↑ 6.0 6.1 Liu, Lina; Su, Guang; Wang, Shuling; Zhu, Bingqian (2018-09-25). "The prevalence of obstructive sleep apnea and its association with pregnancy-related health outcomes: a systematic review and meta-analysis". Sleep and Breathing (Springer Science and Business Media LLC) 23 (2): 399–412. doi:10.1007/s11325-018-1714-7. ISSN 1520-9512. PMID 30255484. 
  7. ↑ 7.0 7.1 Chen, Si-Jing; Shi, Le; Bao, Yan-Ping; Sun, Ye-Kun; Lin, Xiao; Que, Jian-Yu; Vitiello, Michael V.; Zhou, Yu-Xin et al. (2018). "Prevalence of restless legs syndrome during pregnancy: A systematic review and meta-analysis". Sleep Medicine Reviews (Elsevier BV) 40: 43–54. doi:10.1016/j.smrv.2017.10.003. ISSN 1087-0792. PMID 29169861. 
  8. ↑ Gupta, Ravi; Rawat, Vikram Singh (2020). "Sleep and sleep disorders in pregnancy". Handbook of Clinical Neurology. 172. Elsevier. pp. 169–186. doi:10.1016/b978-0-444-64240-0.00010-6. ISBN 9780444642400. 
  9. ↑ 9.0 9.1 9.2 Bušková, Jitka; Miletínová, Eva; Králová, Radana; Dvořáková, Tereza; Tefr Faridová, Adéla; Heřman, Hynek; Hrdličková, Kristýna; Šebela, Antonín (2023-02-18). "Parasomnias in Pregnancy". Brain Sciences (MDPI AG) 13 (2): 357. doi:10.3390/brainsci13020357. ISSN 2076-3425. PMID 36831900. 
  10. ↑ 10.0 10.1 10.2 Lara-Carrasco, Jessica; Simard, Valérie; Saint-Onge, Kadia; Lamoureux-Tremblay, Vickie; Nielsen, Tore (2014). "Disturbed dreaming during the third trimester of pregnancy". Sleep Medicine (Elsevier BV) 15 (6): 694–700. doi:10.1016/j.sleep.2014.01.026. ISSN 1389-9457. PMID 24780135. 
  11. ↑ Habr, Fadlallah; Raker, Christina; Lin, Cui Li; Zouein, Elie; Bourjeily, Ghada (2013). "Predictors of gastroesophageal reflux symptoms in pregnant women screened for sleep disordered breathing: A secondary analysis". Clinics and Research in Hepatology and Gastroenterology (Elsevier BV) 37 (1): 93–99. doi:10.1016/j.clinre.2012.03.036. ISSN 2210-7401. PMID 22572522. 
  12. ↑ Parboosingh, J.; Doig, A. (1973). "Studies of Nocturia in Normal Pregnancy". BJOG: An International Journal of Obstetrics and Gynaecology (Wiley) 80 (10): 888–895. doi:10.1111/j.1471-0528.1973.tb02147.x. ISSN 1470-0328. PMID 4271274. 
  13. ↑ LT, Goldsmith; G, Weiss; BG, Steinetz (1995). "Relaxin and its role in pregnancy". Endocrinology and Metabolism Clinics of North America 24 (1): 171–186. doi:10.1016/S0889-8529(18)30058-6. ISSN 0889-8529. PMID 7781625. https://pubmed.ncbi.nlm.nih.gov/7781625/. 
  14. ↑ Lee, Kathryn A.; Zaffke, Mary Ellen; Baratte-Beebe, Kathleen (2001). "Restless Legs Syndrome and Sleep Disturbance during Pregnancy: The Role of Folate and Iron". Journal of Women's Health & Gender-Based Medicine (Mary Ann Liebert Inc) 10 (4): 335–341. doi:10.1089/152460901750269652. ISSN 1524-6094. PMID 11445024. 
  15. ↑ M I Botez; B Lambert (1977-09-22). "Folate deficiency and restless-legs syndrome in pregnancy". New England Journal of Medicine. Hysterectomies (Massachusetts Medical Society) 297 (12): 670–671. doi:10.1056/nejm197709222971220. ISSN 0028-4793. PMID 895774. 
  16. ↑ Deurveilher, Samüel; Rusak, Benjamin; Semba, Kazue (2011). "Female Reproductive Hormones Alter Sleep Architecture in Ovariectomized Rats". Sleep (Oxford University Press (OUP)) 34 (4): 519–530. doi:10.1093/sleep/34.4.519. ISSN 1550-9109. PMID 21461331. 
  17. ↑ Hirst, Jonathan J.; Haluska, George J.; Cook, Michael J.; Hess, David L.; Novy, Miles J. (1991). "Comparison of Plasma Oxytocin and Catecholamine Concentrations with Uterine Activity in Pregnant Rhesus Monkeys". The Journal of Clinical Endocrinology & Metabolism (The Endocrine Society) 73 (4): 804–810. doi:10.1210/jcem-73-4-804. ISSN 0021-972X. PMID 1890153. 
  18. ↑ 18.0 18.1 Facco, Francesca L.; Chan, Megan; Patel, Sanjay R. (2022-07-06). "Common Sleep Disorders in Pregnancy". Obstetrics & Gynecology (Ovid Technologies (Wolters Kluwer Health)) 140 (2): 321–339. doi:10.1097/aog.0000000000004866. ISSN 0029-7844. PMID 35852285. 
  19. ↑ Bourjeily, Ghada (2009). "Sleep disorders in pregnancy". Obstetric Medicine (SAGE Publications) 2 (3): 100–106. doi:10.1258/om.2009.090015. ISSN 1753-495X. PMID 27582822. 
  20. ↑ American Academy of Sleep Medicine. International Classification of Sleep Disorders, revised: Diagnostic and Coding Manual. Westchester, IL: American Academy of Sleep Medicine, 2000:114–5.
  21. ↑ Schredl, Michael; Gilles, Maria; Wolf, Isabell; Peus, Verena; Scharnholz, Barbara; Sütterlin, Marc; Deuschle, Michael (2016-11-09). "Nightmare frequency in last trimester of pregnancy". BMC Pregnancy and Childbirth (Springer Science and Business Media LLC) 16 (1): 346. doi:10.1186/s12884-016-1147-x. ISSN 1471-2393. PMID 27829406. 
  22. ↑ Chaudhry, Simriti K.; Susser, Leah C. (2018). "Considerations in Treating Insomnia During Pregnancy: A Literature Review". Psychosomatics (Elsevier BV) 59 (4): 341–348. doi:10.1016/j.psym.2018.03.009. ISSN 0033-3182. PMID 29706359. 
  23. ↑ 23.0 23.1 Brunner, Daniel P.; Münch, Magdalena; Biedermann, Kurt; Huch, Renate; Huch, Albert; Borbély, Alexander A. (1994). "Changes in Sleep and Sleep Electroencephalogram During Pregnancy". Sleep (Oxford University Press (OUP)) 17 (7): 576–582. doi:10.1093/sleep/17.7.576. ISSN 1550-9109. PMID 7846455. 
  24. ↑ Maasilta, Paula; Bachour, Adel; Teramo, Kari; Polo, Olli; Laitinen, Lauri A. (2001). "Sleep-Related Disordered Breathing During Pregnancy in Obese Women". Chest (Elsevier BV) 120 (5): 1448–1454. doi:10.1378/chest.120.5.1448. ISSN 0012-3692. PMID 11713118. 
  25. ↑ Tomfohr, Lianne M.; Buliga, Elena; Letourneau, Nicole L.; Campbell, Tavis S.; Giesbrecht, Gerald F. (2015). "Trajectories of Sleep Quality and Associations with Mood during the Perinatal Period". Sleep (Oxford University Press (OUP)) 38 (8): 1237–1245. doi:10.5665/sleep.4900. ISSN 1550-9109. PMID 25845691. 
  26. ↑ Hertz, Gila; Fast, Avital; Feinsilver, Steven H.; Albertario, Claude L.; Schulman, Harold; Fein, Alan M. (1992). "Sleep in Normal Late Pregnancy". Sleep (Oxford University Press (OUP)) 15 (3): 246–251. doi:10.1093/sleep/15.3.246. ISSN 1550-9109. PMID 1621025. 
  27. ↑ Wilson, Danielle L.; Barnes, Maree; Ellet, Lenore; Permezel, Michael; Jackson, Martin; Crowe, Simon F. (2010-12-07). "Decreased sleep efficiency, increased wake after sleep onset and increased cortical arousals in late pregnancy". Australian and New Zealand Journal of Obstetrics and Gynaecology (Wiley) 51 (1): 38–46. doi:10.1111/j.1479-828x.2010.01252.x. ISSN 0004-8666. PMID 21299507. 
  28. ↑ Izci-Balserak, Bilgay; Keenan, Brendan T.; Corbitt, Charles; Staley, Beth; Perlis, Michael; Pien, Grace W. (2018-07-15). "Changes in Sleep Characteristics and Breathing Parameters During Sleep in Early and Late Pregnancy". Journal of Clinical Sleep Medicine (American Academy of Sleep Medicine (AASM)) 14 (7): 1161–1168. doi:10.5664/jcsm.7216. ISSN 1550-9389. PMID 29991418. 
  29. ↑ Gupta, R.; Dhyani, M.; Kendzerska, T.; Pandi-Perumal, S. R.; BaHammam, A. S.; Srivanitchapoom, P.; Pandey, S.; Hallett, M. (2015-10-19). "Restless legs syndrome and pregnancy: prevalence, possible pathophysiological mechanisms and treatment". Acta Neurologica Scandinavica (Hindawi Limited) 133 (5): 320–329. doi:10.1111/ane.12520. ISSN 0001-6314. PMID 26482928. 
  30. ↑ 30.0 30.1 Izci, B. (2006-02-01). "Sleep-disordered breathing and upper airway size in pregnancy and post-partum". European Respiratory Journal (European Respiratory Society (ERS)) 27 (2): 321–327. doi:10.1183/09031936.06.00148204. ISSN 0903-1936. PMID 16452587. 
  31. ↑ Sahin, Figen Kir; Koken, Gulengul; Cosar, Emine; Saylan, Filiz; Fidan, Fatma; Yilmazer, Mehmet; Unlu, Mehmet (2007-10-31). "Obstructive sleep apnea in pregnancy and fetal outcome". International Journal of Gynecology & Obstetrics (Wiley) 100 (2): 141–146. doi:10.1016/j.ijgo.2007.08.012. ISSN 0020-7292. PMID 17976624. 
  32. ↑ 32.0 32.1 Louis, Judette M.; Auckley, Dennis; Sokol, Robert J.; Mercer, Brian M. (2010). "Maternal and neonatal morbidities associated with obstructive sleep apnea complicating pregnancy". American Journal of Obstetrics and Gynecology (Elsevier BV) 202 (3): 261.e1–261.e5. doi:10.1016/j.ajog.2009.10.867. ISSN 0002-9378. PMID 20005507. 
  33. ↑ Olivarez, Sofia; Ferres, Millie; Antony, Katherine; Mattewal, Amarbir; Maheshwari, Bani; Sangi-Haghpeykar, Haleh; Aagaard-Tillery, Kjersti (2011-04-08). "Obstructive Sleep Apnea Screening in Pregnancy, Perinatal Outcomes, and Impact of Maternal Obesity". American Journal of Perinatology (Georg Thieme Verlag KG) 28 (8): 651–658. doi:10.1055/s-0031-1276740. ISSN 0735-1631. PMID 21480159. 
  34. ↑ Miller, Margaret A.; Mehta, Niharika; Clark-Bilodeau, Courtney; Bourjeily, Ghada (2020). "Sleep Pharmacotherapy for Common Sleep Disorders in Pregnancy and Lactation". Chest (Elsevier BV) 157 (1): 184–197. doi:10.1016/j.chest.2019.09.026. ISSN 0012-3692. PMID 31622589. 
  35. ↑ 35.0 35.1 McLafferty, Laura P.; Spada, Meredith; Gopalan, Priya (2022). "Pharmacologic Treatment of Sleep Disorders in Pregnancy". Sleep Medicine Clinics (Elsevier BV) 17 (3): 445–452. doi:10.1016/j.jsmc.2022.06.009. ISSN 1556-407X. PMID 36150806. 
  36. ↑ 36.0 36.1 36.2 "Tiredness and sleep problems". 2023-05-17. https://www.nhs.uk/pregnancy/related-conditions/common-symptoms/tiredness/. 
  37. ↑ 37.0 37.1 "Best Sleeping Positions During Pregnancy". 2021-09-01. https://americanpregnancy.org/healthy-pregnancy/pregnancy-health-wellness/sleeping-positions-while-pregnant/. 
  38. ↑ 38.0 38.1 Raphael-Leff, Joan; Trevarthen, Colwyn; Klaus, Marshall (2018-05-03). Psychological Processes of Childbearing. Routledge. doi:10.4324/9780429482922. ISBN 978-0-429-48292-2. 
  39. ↑ 39.0 39.1 39.2 39.3 39.4 Lara-Carrasco, Jessica; Simard, Valérie; Saint-Onge, Kadia; Lamoureux-Tremblay, Vickie; Nielsen, Tore (2013). "Maternal representations in the dreams of pregnant women: a prospective comparative study". Frontiers in Psychology (Frontiers Media SA) 4: 551. doi:10.3389/fpsyg.2013.00551. ISSN 1664-1078. PMID 23986734. 
  40. ↑ Van, Paulina; Cage, Tene; Shannon, Maureen (2004). "Big Dreams, Little Sleep". Holistic Nursing Practice (Ovid Technologies (Wolters Kluwer Health)) 18 (6): 284–292. doi:10.1097/00004650-200411000-00004. ISSN 0887-9311. PMID 15624275. 
  41. ↑ 41.0 41.1 RL, Blake; J, Reimann (1993). "The pregnancy-related dreams of pregnant women". The Journal of the American Board of Family Practice (J Am Board Fam Pract) 6 (2): 117–122. ISSN 0893-8652. PMID 8452063. https://pubmed.ncbi.nlm.nih.gov/8452063/. 
  42. ↑ 42.0 42.1 Nielsen, Tore; Paquette, Tyna (2007). "Dream-associated Behaviors Affecting Pregnant and Postpartum Women". Sleep (Oxford University Press (OUP)) 30 (9): 1162–1169. doi:10.1093/sleep/30.9.1162. ISSN 0161-8105. PMID 17910388. 
  43. ↑ Ser̀ed, Susan; Abramovitch, Henry (1992). "Pregnant dreaming: Search for a typology of a proposed dream genre". Social Science & Medicine (Elsevier BV) 34 (12): 1405–1411. doi:10.1016/0277-9536(92)90149-k. ISSN 0277-9536. PMID 1529378. 
  44. ↑ Gillman, Robert D. (1968). "The dreams of pregnant women and maternal adaptation.". American Journal of Orthopsychiatry (American Psychological Association (APA)) 38 (4): 688–692. doi:10.1111/j.1939-0025.1968.tb02438.x. ISSN 1939-0025. PMID 5661552. 
  45. ↑ Winget, Carolyn; Kapp, Frederic T. (1972). "The Relationship of the Manifest Content of Dreams to Duration of Childbirth in Primiparae". Psychosomatic Medicine (Ovid Technologies (Wolters Kluwer Health)) 34 (4): 313–320. doi:10.1097/00006842-197207000-00005. ISSN 0033-3174. PMID 5074957. 
  46. ↑ SL, Ablon (1994). "The usefulness of dreams during pregnancy". The International Journal of Psycho-analysis 75 ( Pt 2): 291–299. ISSN 0020-7578. PMID 8063485. https://pubmed.ncbi.nlm.nih.gov/8063485/. 
  47. ↑ Dagan, Yaron; Lapidot, Anat; Eisenstein, Michal (2001). "Women's dreams reported during first pregnancy". Psychiatry and Clinical Neurosciences (Wiley) 55 (1): 13–20. doi:10.1046/j.1440-1819.2001.00778.x. ISSN 1323-1316. PMID 11235851. 

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