Obstructive sleep apnea in pregnancy: Nationwide assessment of obstetric characteristics and maternal morbidity at delivery

Objective

Obstructive sleep apnea (OSA) is associated with cardiovascular, metabolic, and psychiatric conditions in the general population. Less is known about the significance of OSA during pregnancy. The objective of this study was to assess the obstetric characteristics and maternal morbidity associated with OSA during pregnancy at a national scale.

Methods

This cross-sectional study queried the Healthcare Cost and Utilization Project’s National Inpatient Sample in the United States of America. The study population was 18,056,390 hospital deliveries from 2016 to 2020. OSA was identified using the International Classification of Disease Tenth Revision Clinical Modification code G47.33 (n = 22,360). Severe maternal morbidity per the Centers for Disease Control and Prevention definitions was assessed in an N-to-1 propensity score-matched cohort based on pre-pregnant characteristics followed by adjustment for pregnancy confounders in a binary logistic regression model. Patterns of clinical demographics related to OSA were assessed with a classification-tree model.

Results

The coded prevalence of pregnant patients with OSA was 12.4 per 10,000, which increased from 8.5 to 16.6 over a 5-year period (P-trend < 0.001). Patients with OSA were more likely to have a diagnosis of obesity (69.7 % vs 11.4 %, adjusted-odds ratio [aOR] 9.97, 95 % confidence interval [CI] 9.67–10.28), asthma (28.0 % vs 5.2 %, aOR 3.19, 95%CI 3.09–3.29), pre-gestational hypertension (24.8 % vs 2.8 %, aOR 2.77, 95%CI 2.68–2.87), and polycystic ovary syndrome (5.6 % vs 0.7 %, aOR 2.58, 95%CI 2.42–2.74). In the classification-tree model, the coded prevalence rate of OSA increased to 571.4 per 10,000 among pregnant patients with obesity, asthma, and pre-gestational hypertension. In the matched cohort, pregnancy with OSA was associated with gestational hypertension (11.4 % vs 8.7 %, aOR 1.47, 95%CI 1.38–1.57), pre-eclampsia (28.2 % vs 14.7 %, aOR 1.92, 95%CI 1.82–2.02), gestational diabetes (20.1 % vs 13.9 %, aOR 1.45, 95%CI 1.38–1.53), placenta accreta spectrum (0.6 % vs 0.2 %, aOR 1.94, 95%CI 1.35–2.79), extreme preterm delivery (26–33 weeks, 9.3 % vs 4.9 %, aOR 1.53, 95%CI 1.41–1.67), and cesarean delivery (62.3 % vs 50.4 %, aOR 1.42, 95%CI 1.37–1.48). The odds of severe maternal morbidity at delivery was increased in pregnant patients with OSA (6.7 % vs 1.9 %, aOR 2.51, 95%Cl 2.24–2.81), particularly for respiratory morbidity indicators including maternal ventilation (0.8 % vs < 0.1 %, aOR 7.25, 95%CI 4.54–11.56), acute respiratory distress syndrome (2.3 % vs 0.3 %, aOR 4.97, 95%CI 3.88–6.36), and pulmonary edema including acute heart failure (2.0 % vs 0.4 %, aOR 4.06, 95%CI 3.19–5.18). In addition, the odds of peripartum cardiomyopathy increased by nearly seven-fold for the OSA vs non-OSA group (0.6 % vs < 0.1 %, aOR 6.62, 95%CI 3.86–11.36).

Conclusions

This contemporaneous nationwide assessment in the United States suggests that pregnant patients with a diagnosis code of OSA represent a high-risk group that is associated with respiratory and cardiac morbidity at delivery. Although this study is limited by reliance on administrative coding, these results are significant and demonstrate a need for aggressive OSA screening in at-risk groups.