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CC BY-NC-ND 4.0 · Sleep Sci 2022; 15(S 01): 264-277
DOI: 10.5935/1984-0063.20210024
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The cardiovascular, metabolic, fetal and neonatal effects of CPAP use in pregnant women: a systematic review

Debora Petrungaro Migueis
1   Federal Fluminense University, General and specialized surgery - Niterói - RJ -Brazil.
,
Arthur Urel
1   Federal Fluminense University, General and specialized surgery - Niterói - RJ -Brazil.
,
Camila Curado dos Santos
2   Rio de Janeiro Federal University, Gynecology and obstetric - Rio de Janeiro - RJ - Brazil.
,
Andre Accetta
1   Federal Fluminense University, General and specialized surgery - Niterói - RJ -Brazil.
,
Marcelo Burla
1   Federal Fluminense University, General and specialized surgery - Niterói - RJ -Brazil.
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Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea (OSA), but its outcomes for the pregnant are still undefined. This study aims to review current CPAP intervention during pregnancy, discuss published trials, and propose relevant issues that have yet to be addressed satisfactorily about the cardiovascular, metabolic, fetal, and neonatal effects of CPAP treatment during gestation. Two authors independently conducted a systematic review until March 28th, 2021 on PubMed, BVS, and Cochrane Library, using PRISMA guidelines, and risk of bias. Discrepancies were reconciled by a third reviewer. Of 59 identified citations, eight original trials have submitted a total of 90 pregnant women to polysomnography and CPAP therapy. Four studies performed in samples with hypertension or preeclampsia presented blood pressure decrease or maintained the antihypertensive drug dose in the CPAP group. After CPAP utilization, one trial registered cardiac output and stroke volume increase with heart rate and peripheral vascular resistance decrease, which were correlated with birth weight increment. Others documented a higher Apgar in the CPAP group and more fetal movements during CPAP use. There was a reduction in serum uric acid and tumor necrosis factor-alpha in the CPAP groups whose blood pressure decreased. However, two weeks of CPAP use in women with gestational diabetes and OSA did not improve glucose levels but raised the insulin secretion in those adherents to CPAP. Despite these positive results without adverse effects, randomized controlled trials with standardized follow-up in larger populations are required to determine CPAP therapy recommendations in pregnancy.

Continuous Positive Airway Pressure - Obstructive Sleep Apnea - Gestational Diabetes. Preeclampsia - Pregnancy - Hypertension - Pregnancy-Induced

FUNDING SOURCE

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.




Publication History

Article published online:
01 December 2023

© 2023. Brazilian Sleep Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • REFERENCES

  • 1 American Academy of Sleep Medicine (AASM). International classification of sleep disorders. 3rd ed. Darien: AASM; 2014.
  • 2 Bhat S, Gupta D, Akel O, Polos PG, DeBari VA, Akhtar S, et al. The relationships between improvements in daytime sleepiness, fatigue and depression and psychomotor vigilance task testing with CPAP use in patients with obstructive sleep apnea. Sleep Med. 2018 Sep;49:81-9.
  • 3 Darchia N, Oniani N, Sakhelashvili I, Supatashvili M, Basishvili T, Eliozishvili M, et al. Relationship between sleep disorders and health related quality of life–results from the Georgia SOMNUS study. Int J Environ Res Public Health. 2018 Aug;15(8):1588.
  • 4 Punjabi NM, Beamer BA. Alterations in glucose disposal in sleep-disordered breathing. Am J Respir Crit Care Med. 2009 Feb;179(3):235-40.
  • 5 Kheirandish-Gozal L, Gozal D. Obstructive sleep apnea and inflammation: proof of concept based on two illustrative cytokines. Int J Mol Sci. 2019 Jan;20(3):459.
  • 6 Nadeem R, Molnar J, Madbouly EM, Nida M, Aggarwal S, Sajid H, et al. Serum inflammatory markers in obstructive sleep apnea: a meta-analysis. J Clin Sleep Med. 2013 Oct;9(10):1003-12.
  • 7 Bourjeily G, Danilack VA, Bublitz MH, Lipkind H, Muri J, Caldwell D, et al. Obstructive sleep apnea in pregnancy is associated with adverse maternal outcomes: a national cohort. Sleep Med. 2017;38:50-7.
  • 8 Pamidi S, Pinto LM, Marc I, Benedetti A, Schwartzman K, Kimoff RJ. Maternal sleep-disordered breathing and adverse pregnancy outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol. 2014;210(1):52e1-e14.
  • 9 Sweed RA, Hassan S, ElWahab NHA, Aref SR, Mahmoud MI. Comorbidities associated with obstructive sleep apnea: a retrospective Egyptian study on 244 patients. Sleep Breath. 2019 Dec;23(4):1079-85.
  • 10 Chirakalwasan N, Amnakkittikul S, Wanitcharoenkul E, Charoensri S, Saetung S, Chanprasertyothin S, et al. Continuous positive airway pressure therapy in gestational diabetes with obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med. 2018 Mar;14(3):327-36.
  • 11 Arzt M, Young T, Finn L, Skatrud JB, Bradley TD. Association of sleepdisordered breathing and the occurrence of stroke. Am J Respir Crit Care Med. 2005 Dec;172(11):1447-51.
  • 12 Poyares D, Guilleminault C, Hachul H, Fujita L, Takaoka S, Tufik S, et al. Pre-eclampsia and nasal CPAP: part 2. Hypertension during pregnancy, chronic snoring, and early nasal CPAP intervention. Sleep Med. 2007 Dec;9(1):15-21.
  • 13 Punjabi NM, Shahar E, Redline S, Gottlieb DJ, Givelber R, Resnick HE. Sleep-disordered breathing, glucose intolerance, and insulin resistance: the Sleep Heart Health study. Am J Epidemiol. 2004 Sep;160(6):521-30.
  • 14 Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet. 2014 Feb;383(9918):736-47.
  • 15 Reid J, Taylor-Gjevre R, Gjevre J, Skomro R, Fenton M, Olatunbosun F, et al. Can gestational hypertension be modified by treating nocturnal airflow limitation?. J Clin Sleep Med. 2013 Apr;9(4):311-7.
  • 16 Ravishankar S, Bourjeily G, Lambert-Messerlian G, He M, De Paepe ME, Gündogan F. Evidence of placental hypoxia in maternal sleep disordered breathing. Pediatr Dev Pathol. 2015 Sep/Oct;18(5):380-6.
  • 17 Thangaratinam S, Ismail KMK, Sharp S, Coomarasamy A, Khan KS. Accuracy of serum uric acid in predicting complications of preeclampsia: a systematic review. BJOG. 2006 Apr;113(4):369-78.
  • 18 Hirotsu C, Tufik S, Guindalini C, Mazzotti DR, Bittencourt LR, Andersen ML. Association between uric acid levels and obstructive sleep apnea syndrome in a large epidemiological sample. PLoS One. 2013 Jun;8(6):e66891.
  • 19 Maruhashi T, Hisatome I, Kihara Y, Higashi Y. Hyperuricemia and endothelial function: from molecular background to clinical perspectives. Atherosclerosis. 2018 Nov;278:226-31.
  • 20 Ioachimescu AG, Brennan DM, Hoar BM, Hazen SL, Hoogwerf BJ. Serum uric acid is an independent predictor of all-cause mortality in patients at high risk of cardiovascular disease: a preventive cardiology information system (PreCIS) database cohort study. Arthritis Rheum. 2008 Feb;58(2):623-30.
  • 21 Steiropoulos P, Kotsianidis I, Nena E, Tsara V, Gounari E, Hatzizisi O, et al. Long-term effect of continuous positive airway pressure therapy on inflammation markers of patients with obstructive sleep apnea syndrome. Sleep. 2009 Apr;32(4):537-43.
  • 22 Epstein LJ, Kristo D, Strollo Junior PJ, Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and longterm care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009 Jun;5(3):263-76.
  • 23 Bourjeily G, Ankner G, Mohsenin V. Sleep-disordered breathing in pregnancy. Clin Chest Med. 2011 MAr;32(1):175-89.
  • 24 Pien GW, Pack AI, Jackson N, Maislin G, Macones GA, Schwab RJ. Risk factors for sleep-disordered breathing in pregnancy. Thorax. 2014 Apr;69(4):371-7.
  • 25 Pamidi S, Kimoff RJ. Maternal sleep-disordered breathing. Chest. 2018 Apr;153(4):1052-66.
  • 26 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffman TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev. 2021 Mar;29;18(3):e1003583.
  • 27 Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, et al. American Academy of Sleep Medicine. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events: deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2012 Oct;8(5):597-619.
  • 28 Collop NA, Tracy SL, Kapur V, Mehra R, Kuhlmann D, Fleishman SA. Obstructive sleep apnea devices for out-of-center (OOC) testing: technology evaluation. J Clin Sleep Med. 2011 Oct;7(5):531-48.
  • 29 Nacional Heart, Lung and Blood Institute (NIH). Guidance for assessing the quality of observational cohort and cross [Internet]. Bethesda: NIH; 2020; [access in ANO Mês dia]. Available from: https://www.nhlbi.nih. gov/health-topics/study-quality-assessment-tools
  • 30 Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991 Dec;14(6):540-5.
  • 31 Bertolazi AN, Fagondes SC, Hoff LS, Pedro VD, Barreto SSM, Johns MW. Portuguese-language version of the Epworth sleepiness scale: validation for use in Brazil. J Bras Pneumol. 2009;35(9):877-83.
  • 32 Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989 May;28(2):193-213.
  • 33 Sedov ID, Cameron EE, Madigan S, Tomfohr-Madsen LM. Sleep quality during pregnancy: a meta-analysis. Sleep Med Rev. 2018;38:168-76.
  • 34 Guilleminault C, Palombini L, Poyares D, Takaoka S, Huynh NTL, El- Sayed Y. Pre-eclampsia and nasal CPAP: Part 1. Early intervention with nasal CPAP in pregnant women with risk-factors for pre-eclampsia: preliminary findings. Sleep Med. 2007 Dec;9(1):9-14.
  • 35 Blyton DM, Sullivan CE, Edwards N. Reduced nocturnal cardiac output associated with preeclampsia is minimized with the use of nocturnal nasal CPAP. Sleep. 2004 Feb;27(1):79-84.
  • 36 Chan G, Cooper R, Hosanee M, Welykholowa K, Kyriacou PA, Zheng D, et al. Multi-site photoplethysmography technology for blood pressure assessment: challenges and recommendations. J Clin Med. 2019 Nov;8(11):1827.
  • 37 Guilleminault C, Poyares D, Rosa A, Huang YS. Heart rate variability, sympathetic and vagal balance and EEG arousals in upper airway resistance and mild obstructive sleep apnea syndromes. Sleep Med. 2005 Sep;6(5):451-7.
  • 38 Lopes MC, Spruyt K, Azevedo-Soster L, Rosa A, Guilleminault C. Reduction in parasympathetic tone during sleep in children with habitual snoring. Front Neurosci. 2019;12:997.
  • 39 Edwards N, Blyton DM, Kirjavainen T, Kesby GJ, Sullivan CE, Kgv GV, et al. Reduces sleep-induced blood pressure increments in preeclampsia. Am J Respir Crit Care Med. 2000;162:252-7.
  • 40 Bublitz MH, Carpenter M, Amin S, Okun ML, Millman R, De La Monte SM, et al. The role of inflammation in the association between gestational diabetes and obstructive sleep apnea: a pilot study. Obstet Med. 2018 Dec;11(4):186-91.
  • 41 Sari O, Akpak YK, Yerebasmaz N, Arslan I, Dagcioglu BF, Oral S. Evaluation of obstructive sleep apnea prevalence in mothers of infants with low birth weight and its relationship with serum uric acid levels as a hypoxia marker. J Matern Fetal Neonatal Med. 2020;5:1-8.
  • 42 Blyton DM, Skilton MR, Edwards N, Hennessy A, Celermajer DS, Sullivan CE. Treatment of sleep disordered breathing reverses low fetal activity levels in preeclampsia. Sleep. 2013 Jan;36(1):15-21.
  • 43 Leech JA. The feasibility of adding fetal heart rate to the nocturnal polysomnogram. J Clin Sleep Med. 2007;3(3):277-80.
  • 44 Kobayashi H, Yoshida A, Kobayashi M, Hamada T, Noguchi Y, Yamada T. A new computerized analysis to precisely evaluate heart rate variability during the nonstress test. Am J Perinatol. 2003;20(2):77-85.
  • 45 American Academy of Pediatrics Committee on Fetus and Newborn; American College of Obstetricians and Gynecologists Committee on Obstetric Practice. The Apgar score. Pediatrics. 2015 Oct;136(4):819-22.
  • 46 Guilleminault C, Kreutzer M, Chang JL. Pregnancy, sleep disordered breathing and treatment with nasal continuous positive airway pressure. Sleep Med. 2004 Jan;5(1):43-51.
  • 47 Pamidi S, Meltzer SJ, Garfield N, Lavigne L, Olha A, Khalyfa A, et al. A pilot randomized-controlled trial on the effect of CPAP treatment on glycemic control in gestational diabetes: study design and methods. Front Endocrinol (Lausanne). 2018;9:659.
  • 48 O’Brien LM, Bullough AS, Shelgikar AV, Chames MC, Armitage R, Chervin RD. Validation of watch-PAT-200 against polysomnography during pregnancy. J Clin Sleep Med. 2012 Jun;8(3):287-94.
  • 49 Spicuzza L, Caruso D, Di Maria G. Obstructive sleep apnoea syndrome and its management. Ther Adv Chronic Dis. 2015 Sep;6(5):273-85.
  • 50 Sforza E, Krieger J, Weitzenbwm E, Apprill M, Lampert E, Ratamaharo J. Long-term effects of treatment with nasal continuous positive airway pressure on daytime lung function and pulmonary hemodynamics in patients with obstructive sleep apnea. Am Rev Respir Dis. 1990 Apr;141(4 Pt 1):866-70.
  • 51 Leech JÁ, Onal E, Lopata M. Nasal CPAP continues to improve sleepdisordered breathing and daytime oxygenation over long-term follow-up of occlusive sleep apnea syndrome. Chest. 1992 Dec;102(6):1651-5.
  • 52 Doherty LS, Kiely JL, Swan V, McNicholas WT. Long-term effects of nasal continuous positive airway pressure therapy on cardiovascular outcomes in sleep apnea syndrome. Chest. 2005 Jun;127(6):2076-84.
  • 53 Eliasson A. Effect of continuous positive airway pressure on inflammatory markers. Chest. 2010 Aug;138(2):463.
  • 54 Sánchez-De-La-Torre M, Khalyfa A, Sánchez-De-La-Torre A, Martinez- Alonso M, Martinez-García MÁ, Barceló A, et al. Precision medicine in patients with resistant hypertension and obstructive sleep apnea blood pressure response to continuous positive airway pressure treatment. J Am Coll Cardiol. 2015 Sep;66(9):1023-32.
  • 55 Saarelainen S, Hasan J, Siitonen S, Seppälä E. Effect of nasal CPAP treatment on plasma volume, aldosterone and 24-h blood pressure in obstructive sleep apnoea. J Sleep Res. 1996 Sep;5(3):181-5.
  • 56 Dawson A, Abel SL, Loving RT, Dailey G, Shadan FF, Cronin JW, et al. CPAP therapy of obstructive sleep apnea in type 2 diabetics improves glycemic control during sleep. J Clin Sleep Med. 2008 Dec;4(6):538-43.
  • 57 Harsch IA, Schahin SP, Brückner K, Radespiel-Tröger M, Fuchs FS, Hahn EG, et al. The effect of continuous positive airway pressure treatment on insulin sensitivity in patients with obstructive sleep apnoea syndrome and type 2 diabetes. Respiration. 2004 May/Jun;71(3):252-9.
  • 58 West SD, Nicoll DJ, Wallace TM, Matthews DR, Stradling JR. Effect of CPAP on insulin resistance and HbA1c in men with obstructive sleep apnoea and type 2 diabetes. Thorax. 2007 Nov;62(11):969-74.
  • 59 Baessler A, Nadeem R, Harvey M, Madbouly E, Younus A, Sajid H, et al. Treatment for sleep apnea by continuous positive airway pressure improves levels of inflammatory markers - a meta-analysis. J Inflamm (London). 2013 Mar;10:13.
  • 60 Kohler M, Ayers L, Pepperell JCT, Packwood KL, Ferry B, Crosthwaite N, et al. Effects of continuous positive airway pressure on systemic inflammation in patients with moderate to severe obstructive sleep apnoea: a randomised controlled trial. Thorax. 2009;64(1):67-73.
  • 61 Lacasse Y, Godbout C, Sériès F. Health-related quality of life in obstructive sleep apnoea. Eur Respir J. 2002 Mar;19(3):499-503.
  • 62 Mulgrew AT, Ryan CF, Fleetham JA, Cheema R, Fox N, Koehoorn M, et al. The impact of obstructive sleep apnea and daytime sleepiness on work limitation. Sleep Med. 2007 Dec;9(1):42-53.
  • 63 Young T, Finn L, Peppard PE, Szklo-coxe M, Austin D, Nieto FJ, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep. 2008 Aug;31(8):1071-8.
  • 64 AlGhanim N, Comondore VR, Fleetham J, Marra CA, Ayas NT. The economic impact of obstructive sleep apnea. Lung. 2008;186(1):7-12.
  • 65 Bourjeily G, Barbara N, Larson L, He M. Clinical manifestations of obstructive sleep apnoea in pregnancy: More than snoring and witnessed apnoeas. J Obstet Gynaecol. 2012 Jul;32(5):434-8.
  • 66 Gathiram P, Moodley J. Pre-eclampsia: its pathogenesis and pathophysiology. Cardiovasc J Afr. 2016 Mar/Apr;27(2):71-8.
  • 67 Drager LF, Togeiro SM, Polotsky VY, Lorenzi-Filho G. Obstructive sleep apnea: a cardiometabolic risk in obesity and the metabolic syndrome. J Am Coll Cardiol. 2013 Aug;62(7):569-76.
  • 68 Olivarez SA, Maheshwari B, McCarthy M, Zacharias N, Van Den Veyver I, Casturi L, et al. Prospective trial on obstructive sleep apnea in pregnancy and fetal heart rate monitoring. Am J Obstet Gynecol. 2010 Jun;202(6):552 e1-7.
  • 69 Reid J, Skomro R, Gjevre J, Cotton D, Ward H, Olatunbosun O. Fetal heart rate monitoring during nocturnal polysomnography. Clin Exp Obstet Gynecol. 2011;38(2):123-5.
  • 70 Lam C, Lim KH, Kang DH, Karumanchi SA. Uric acid and preeclampsia. Semin Nephrol. 2005 Jan;25(1):56-60.
  • 71 Guilleminault C, Kirisoglu C, Ohayon MM. C-reactive protein and sleep-disordered breathing. Sleep. 2004 Dec;27(8):1507-11.
  • 72 Chen Q, Lin G, Chen L, Huang J, Huang Y, Li P, et al. Does continuous positive airway pressure therapy in patients with obstructive sleep apnea improves uric acid? A meta-analysis. Oxid Med Cell Longev. 2019;2019:4584936.
  • 73 Ryan S, Taylor CT, McNicholas WT. Selective activation of inflammatory pathways by intermittent hypoxia in obstructive sleep apnea syndrome. Circulation. 2005 Oct;112(17):2660-7.
  • 74 Savransky V, Nanayakkara A, Li J, Bevans S, Smith PL, Rodriguez A, et al. Chronic intermittent hypoxia induces atherosclerosis. Am J Respir Crit Care Med. 2007 Jun;175(12):1290-7.
  • 75 Garvey JF, Taylor CT, McNicholas WT. Cardiovascular disease in obstructive sleep apnoea syndrome: the role of intermittent hypoxia and inflammation. Eur Respir J. 2009 May;33(5):1195-205.
  • 76 Davies CR, Harrington JJ. Impact of obstructive sleep apnea on neurocognitive function and impact of continuous positive air pressure. Sleep Med Clin. 2016 Sep;11(3):287-98. DOI: http://dx.doi. org/10.1016/j.jsmc.2016.04.006
  • 77 James PT, Leach R, Kalamara E, Shayeghi M. The worldwide obesity epidemic. Obes Res. 2001 Nov;9(Suppl 4):228S-33S.
  • 78 Pi-Sunyer FX. The obesity epidemic: pathophysiology and consequences of obesity. Obes Res. 2002 Dec;10(Suppl 2):97S-104S.
  • 79 Antony KM, Agrawal A, Arndt ME, Murphy AM, Alapat PM, Guntupalli KK, et al. Association of adverse perinatal outcomes with screening measures of obstructive sleep apnea. J Perinatol. 2014 Jun;34(6):441-8.
  • 80 Lockhart EM, Abdallah AB, Tuuli MG, Leighton BL. Obstructive sleep apnea in pregnancy. Obstet Gynecol. 2015 Jul;126(1):93-102.
  • 81 Tantrakul V, Sirijanchune P, Panburana P, Pengjam J, Suwansathit W, Boonsarngsuk V, et al. Screening of obstructive sleep apnea during pregnancy: differences in predictive values of questionnaires across trimesters. J Clin Sleep Med. 2015 Jan;11(2):157-63.
  • 82 Facco FL, Ouyang DW, Zee PC, Grobman WA. Development of a pregnancy-specific screening tool for sleep apnea. J Clin Sleep Med. 2012 Aug;8(4):389-94.
  • 83 White DP. Advanced concepts in the pathophysiology of obstructive sleep apnea. Adv Otorhinolaryngol. 2017;80:7-16.
  • 84 Malhotra RK, Kirsch DB, Kristo DA, Olson EJ, Aurora RN, Carden KA, et al. Polysomnography for obstructive sleep apnea should include arousal-based scoring: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2018 Jul;14(7):1245-7.
  • 85 Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993 Apr;328(17):1230-5.
  • 86 Ashley EA. Towards precision medicine. Nat Rev Genet. 2016 Aug;17(9):507-22.
  • 87 Lamberti MJ, Wilkinson M, Peña Y, Getz K, Beltre C. Preparing for precision medicine. Contract Pharma. 2018 Jan;(1-2):489-91.
  • 88 Jameson JL, Longo DL. Precision medicine: personalized, problematic, and promising. N Engl J Med. 2015 Jun;372(23):2229-34.