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Sleep in pregnancy and the post-partum period

Maternal sleep quality declines during pregnancy, beginning in the first trimester and worsening significantly in the third trimester. This deterioration often persists into the postpartum period and, in some cases, may become chronic. Four primary sleep disorders can be identified in pregnancy:

  1. Insomnia – Characterized by difficulty initiating and maintaining sleep, insomnia in pregnancy has a multifactorial etiology. Contributing factors include physical discomfort (such as hyperemesis, nocturia, musculoskeletal pain, gastroesophageal reflux, nasal congestion, thermoregulatory disturbances, uterine contractions, fetal movements, and altered sleeping positions), hormonal changes leading to increased sleep fragmentation, and psychological factors, particularly depression and anxiety. Poor sleep quality has been associated with an increased risk of adverse pregnancy outcomes, including gestational diabetes, preterm birth, prolonged labor, and a higher likelihood of cesarean delivery.

  2. Obstructive Sleep Apnea (OSA) – The prevalence of OSA increases as pregnancy progresses due to physiological and hormonal changes that predispose individuals to upper airway obstruction. These changes include a progressive reduction in functional residual capacity, decreased expiratory reserve volume, elevation of the diaphragm by approximately 4 cm, alterations in lung resting position, and relaxation of ligamentous attachments of the ribs. OSA has been linked to an elevated risk of gestational diabetes, hypertensive disorders of pregnancy, fetal growth restriction, preterm birth, cesarean delivery, and neonatal intensive care unit admissions. While OSA and preeclampsia share common pathophysiological mechanisms, further research is required to fully elucidate their relationship.

  3. Limb Movement Disorders – This category encompasses a range of neurosensory movement disorders, with restless leg syndrome (RLS) being particularly prevalent in pregnancy. RLS is closely associated with iron deficiency and has been linked to an increased risk of hypertensive disorders in pregnancy.

  4. Sleep and Mental Health in the Postpartum Period – Sleep deprivation, combined with hormonal fluctuations, plays a significant role in postpartum mental health deterioration. Mood disorders are both a cause and a consequence of sleep disturbances, highlighting the bidirectional relationship between sleep and psychological well-being. Obstetricians should remain vigilant regarding these interconnections when managing pregnant and postpartum individuals.

Sleep in the peri-menopause period

Perimenopause is a transition from the late female reproductive stage to end of the first year after the last menstrual period. This phase is characterized by noticeable changes in the menstrual cycles as well as fluctuation and eventual cessation of ovarian hormone production.

The interrelated biological, psychological and social changes that women may experience during menopausal transition increase the risk for insomnia, sleep related breathing disorders and other sleep conditions in this life period.

The most common sleep related complaints are difficulty with maintaining sleep and early morning final awakening affecting approximately 50% of women who are going through menopause. These symptoms may be mild and do not significantly disrupt sleep or may be distressing and impact daytime well being. Questionnaires, for example the Insomnia Severity Index, are useful tools to help determine if the insomnia symptoms are clinically significant and likely meet criteria for chronic insomnia disorder.

The prevalence of sleep related breathing disorders (for example, obstructive sleep apnea) also increases during the menopausal transition period. These conditions can cause or worsen nighttime and daytime insomnia symptoms. Screening for sleep apnea is important during medical visits in the perimenopausal period with special attention to snoring, frequent nighttime urination, weight gain, excessive daytime fatigue or sleepiness, and mood problems.

Habitual early morning final awakening in the peri and post menopausal period can indicate a shift in circadian rhythm. If the sleep diary shows that the typical sleep phase is unusually early or late, it is important to consider the possibility of a circadian rhythm sleep wake disorder, which requires special diagnosis (dim light melatonin onset test) and treatment.

The first line recommended treatment for insomnia disorder in the perimenopausal period is cognitive behavioural therapy (CBT) for insomnia. This treatment is effective even when other medical and psychological issues are present. Menopausal hormone therapy (MHT) is an effective treatment for vasomotor symptoms (hot flashes and night sweats). Research studies testing if MHT improves sleep have shown mixed results: about half of high-quality studies have shown that MHT ameliorates insomnia symptoms, while other rigorous studies did not detect a beneficial effect. There is also insufficient evidence to support that MHT would improve sleep-related breathing disorders in the perimenopausal period.

Referral to an insomnia specialist or to a sleep clinic is warranted if symptoms do not sufficiency improve after evidence-based treatment have been implemented. Furthermore, referral is recommended if there are symptoms that may warrant special consideration, for example, unusually early or late sleep onset and wake time; excessive sleepiness; or other symptoms that may indicate a presence of circadian disorders, sleep apnea or other comorbid sleep disorders.