May 7, 2012
Here’s a not-to-surprising study showing that obese women are at higher risk of having children with autism. Obese women were 67% more likely to have an autistic child, and about 2x as likely to have an child with another developmental disorder. Having gestational diabetes also raised by 2x a mother’s risk of having a baby with developmental disorders.
They also note that nearly 60% of women of childbearing age in the US is overweight and about 1/3 are obese. Obesity rates are rapidly climbing. Autism rates are also climbing, with the latest report showing 1/88 children having one of the autism spectrum disorders.
The authors mentioned every possible explanation (diabetes, high blood pressure, fluctuating glucose levels, lack of oxygen) expect for obstructive sleep apnea. I’ve written numerous times in the past about complications of obstructive sleep apnea during pregnancy. If you’re overweight or obese, you’re much more likely to have obstructive sleep apnea. One of the hallmarks of sleep apnea is hypoxia and major physiologic stress on the mother’s body. I wonder what the effect is on the developing baby’s brain? It would make sense to routinely screen for sleep apnea in all women, especially if you’re overweight or heavier.
If you were overweight during pregnancy, did your doctor screen you for obstructive sleep apnea?
August 21, 2011
Having an asthma attack in the middle of the night can be a frightening and terrifying experience. Typically, these attacks happen in the early morning hours, just before awakening.
Now there’s research showing that poorly controlled asthma during pregnancy can increase a woman’s chances of developing preeclampsia (50%) and premature births (25%). Furthermore, infants born to mothers with poorly controlled asthma delivered babies that were about 0.2 pounds less than those born to mothers without asthma.
We typically think of asthma being a separate, distinct condition from obstructive sleep apnea, and it’s treated in completely different ways. However, it’s not just coincidence that nocturnal awakenings from asthma and the most intense periods of apnea occur at the same time in the middle of the night—the early morning hours. The early morning hours are when REM sleep is most prominent, and this is the time when throat muscles are most relaxed. Having an apnea also is known to cause reflex, which is known to reach the throat as well as the nose and the lungs. In one small study in people with sleep apnea and asthma, treating sleep apnea with CPAP significantly improved nocturnal asthma symptoms.
We know that any degree of stress on the mother’s body can lead to a higher rate of pregnancy-related complications and low birth rates. Even snoring by the mother alone was found to result in lower Apgar scores in newborn infants. Apneas are also known to raise blood pressure and promote insulin resistance. Stress hormones are also known to increase when you have apneas.
In light of all these findings, it’s not surprising that pregnant women with poorly controlled asthma have higher complications rates. This is another great example of “connecting the dots” between two seemingly unrelated conditions, which only adds to support my sleep-breathing paradigm.
August 3, 2011
As a follow-up to my post last week on why pregnant women may have an increased risk of stroke, here’s a study published this month in the journal Sleep. Researchers compared 34 women with gestational hypertension vs. 26 healthy women with uncomplicated pregnancies. Significant sleep-disordered breathing was defined as a respiratory disturbance index (RDI) of 5. Pregnant women with high blood pressure had significant sleep-disordered breathing in 53%, whereas 12% of healthy pregnant women had sleep-disordered breathing. Hypertension is a known risk factor for preeclampsia and stroke.
This study is in line with my suspicion that pregnant women, while at risk for obstructive sleep apnea, probably have shorter obstructions and RERAs (respiratory-effort related arousals), rather than frank apneas. Increased progesterone and various other physiologic changes seen in pregnancy can increase your respiratory drive and lower arousal thresholds, leading to more frequent arousals from deep sleep.
Notice how commonly pregnant women snore, and they’re extremely tired. If they weren’t pregnant, doctors would suspect obstructive sleep apnea. Then why do we have this double standard? Why can’t women who suddenly gain weight and snore be routinely screened for obstructive sleep apnea?
July 28, 2011
Rates of stroke went up 47% for expectant mothers and climbed to 83% in the first three months after delivery. This was the finding that was published in the journal Stroke: Journal of the American Heart Association. They cite rising rates of additional risk factors such as high blood pressure, obesity, and gestational diabetes, but didn’t give a plausible explanation. Here’s a story about this study published in the Wall Street Journal.
Here’s a simple explanation: Sleep-breathing problems. Whether it’s obstructive sleep apnea or more likely upper airway resistance syndrome, pregnant women tend to have more frequent breathing pauses, especially as they gain weight. One protective mechanism is through progesterone, which acts as a tongue muscle stimulant, but the forces of upper airway collapse is likely to overwhelm these protective effects. What’s even more striking is that the rate almost doubles immediately postpartum. Remember that progesterone drops soon after delivery, but you’re still left with all that additional weight. We know that obstructive sleep apnea can significantly increase your chances of stroke and heart attacks. There are even reports that suggest that preeclampsia can be successfully treated with CPAP.
Overall, the numbers are still very low, but the sudden rise in the rate of stroke in new mothers leaves researchers scratching their heads.
June 19, 2011
Researchers from New Zealand discovered that women who did not sleep on their left side the last night before delivering their babies had twice the rate of stillbirth compared with those that slept on their left side. It’s commonly recommended for pregnant women to sleep on their left side, especially later in pregnancy. There are various explanations for why this is preferred, from placing less pressure on the mother’s major blood vessels to worsening the mother’s snoring.
I’ve mentioned before that a woman’s risk of developing obstructive sleep apnea increases as she gains weight during pregnancy, but progesterone counteracts this effect neuromuscularly, by tensing the throat muscles and increasing the drive to breathe. However, back sleeping is a known aggravator of breathing pauses during sleep due to gravity’s effects on the tongue. Whether or not this leads to apneas (10 seconds or longer pauses), the mother will still stop breathing and wake up more often during the night. This can place a major stress not only on the mother’s body, but on the baby as well.
This study was an observational study, so more prospective studies are needed. But it only goes to show that any additional situation that can aggravate sleep-breathing problems during pregnancy can raise your risk of complications, which also includes gestational diabetes and preeclampsia.
I wonder if the researchers asked the women what their preferred pre-pregnancy sleep position was. I suspect that women who can’t sleep on their backs may have more complications during pregnancy due to narrowed upper airway anatomy.
April 8, 2011
A new study published this week in the Journal Human Reproduction found that obese pregnant women have a much higher chance of miscarriage or suffering from their child dying before the first birthday. Not too surprisingly, pre-eclampsia was the most common reason for these obesity-related deaths. Gestational diabetes increased as well.
We know that any significant weight gain can lead to obstructive sleep apnea. Then why is it that pregnant women don’t develop sleep apnea? One possible reason why this may not happen as often is that progesterone increases significantly during pregnancy. Progesterone is an upper airway muscle stimulant, increasing tongue muscle tone significantly. This is one way it protects against apnea-promoting effects of weight gain.
However, if you gain too much weight, or if there are other stresses in your life that hormonally diminishes the protective effects of progesterone, then you’ll have more problems breathing at night, leading to or aggravating various pregnancy complications. High blood pressure (seen in pre-eclampsia), and diabetes are more likely in people with sleep apnea.
What’s just as important is what happens after delivery: Progesterone drops, but you’re left with all that weight. By definition, your sleep quality will drop significantly. This is one mechanism that can aggravate post-partum depression. Imagine how much worse it may be if you also lose your child.
If you’re a woman and are overweight and have sleep apnea, did you suffer any miscarriages or pregnancy complications in the past?
February 18, 2011
February is American Heart Month, and one thing that’s being stressed more this year is the fact that many women’s heart problems go undiagnosed, especially if they have atypical symptoms. The American Heart Association just recently came out with revised guidelines of cardiovascular disease prevention for women. The two interesting points they make is that women have a higher proportion of strokes to heart attacks compared with men. The other point they at emphasize is the fact that if you had a complication during pregnancy, your risk of heart disease later in life is significantly higher.
What was surprising to me is that we have lots of studies showing that most cases of pregnancy-related complications such as preeclampsia and gestational diabetes may be caused by untreated obstructive sleep apnea. Since weight gain is a major risk for sleep apnea, why should pregnant women be excluded from having a sleep-breathing disorder? By definition, pregnancy will cause you to have temporary sleep-breathing problems, whether or not it’s officially obstructive sleep apnea.
The one thing that protects against sleep apnea during pregnancy is the rise in progesterone, which acts as an upper airway muscle stimulant, but this can only help so much. As progesterone drops after delivery, what do you think will happen to women who still have most their pregnancy weight? I’m willing to bet that if you do the same study looking at post-partum complications such as postpartum depression, you’ll see the same increased rate of heart disease later in life.
The shocking thing was that nowhere in these general guidelines do they even mention looking for obstructive sleep apnea. I won’t begin to talk about the link between stroke and sleep apnea–there are just too many studies to mention. I encourage you to take a look at the recommendations of the American Heart Association’s website. Tell me what you think about this glaring omission.
January 1, 2011
I came across a post in KevinMD with stories from women (many in their 30s and 40s) who suffered from serious heart attacks. I commented on this post in #5. I strongly urge you to read the entire article. I’ve also posted my reply below:
Wow! I was riveted while I read through the entire post. We know that younger women can have heart attacks, and it’s acknowledged that doctors are not good at picking up heart attack symptoms in younger women.
Here are a few observations that I had:
1. Many of the women had heart attacks from 3-5 AM. One study showed that people with obstructive sleep apnea have heart attacks during this timeframe, as compared to earlier in the morning in people who don’t have sleep apnea and have heart attacks.
2. Many women also described severe heartburn as a major symptom. If these women were having a sudden increase in the number and severity of apneas, then it’s expected to have more severe reflux, due to the negative pressures in the chest. One woman, Lidia, had too much to eat and drink for her birthday. Alcohol relaxes your throat muscles, and additional reflux from stomach juices can cause more obstructions and arousals.
3. One woman described recent 10 pounds weight gain—an additional risk for obstructive sleep apnea.
4. Also notice how many women either were pregnant or post-partum. Weight gain during pregnancy is a major risk for obstructive sleep apnea, which can lead to pre-eclampsia and gestational diabetes. That’s also why pregnancy complications are linked to a higher rate of heart disease—because you’re at risk for having obstructive sleep apnea. Post-partum, the protective effect of progesterone is gone (progesterone tenses your upper airway dilators), and more frequent breathing pauses can tip you over the edge.
5. I’m willing to bet that many of these women snored, but it’s also been shown that you can be young, thin and not snore to have significant obstructive sleep apnea. What I’m sure of is that one or both parents of these women snores heavily, with major cardiovascular disease. Typically, these women won’t be able to sleep on their backs, due to smaller oral cavity jaw structures, which narrows the posterior airway space. Deep sleep will relax the muscles, making them more prone to breathing pauses.
6. Some of the women also mentioned casually that they were sleep deprived. Not sleeping enough can be a major trigger to cause major sympathetic stimulation when normally, you’re not ever able to get efficient sleep at all.
7. I bet that most of these women, even when younger, never felt refreshed, no matter how long they slept. Typically, these women will attribute their fatigue to anemia, stress, TMJ, sinus infections, migraines, hypothyroidism, insomnia or chronic fatigue. Many will also have cold hands or feet, and oftentimes, blood pressure will be one the low side, especially when younger (later on, the BP normalizes and then goes high). This is called upper airway resistance syndrome, a variation of obstructive sleep apnea, where you can stop breathing 10 to 20 times per hours and not have official sleep apnea on a sleep study.
It’s important to pick up the atypical symptoms of heart attack in women, but what’s just as important is to treat what’s actually aggravating, if not causing the heart disease. If this had been done months or years prior to their heart attacks, many of these cardiac events could have been prevented.
In these women, there was usually some trigger that tipped them over the edge, whether it’s weight gain, eating late, severe stress, drinking alcohol, pregnancy, or even weather changes. There’s so much proven evidence showing that most people with heart disease have (or will have) significant obstructive sleep apnea. Physicians have to erase the image of the traditional sleep apnea patient as being overweight, snoring, male, with a big neck. Sleep apnea is a craniofacial, anatomic problem due to smaller jaws. Obesity comes later, which only makes the problem worse.
Learning the benefits of the Coronary Artery Bypass Surgery versus traditional surgery may be a good option for women who currently suffer from heart problems.