Obstructive sleep apnea screening in pregnancy, perinatal outcomes, and impact of maternal obesity.

We employed accepted, validated symptom-based screening measures to discern attributable risk of obstructive sleep apnea (OSA) to adverse pregnancy outcomes, taking into account potential maternal confounders. Commonly employed OSA screening measures (Berlin and Epworth scales) were performed in the second and third trimesters; maternal and neonatal outcome data were thereafter obtained. The relationship between OSA and outcomes of interest were explored in stratified and multivariate models controlling for potential confounders. The overall prevalence of OSA was 25.4%. Given a nonlinear increase by body mass index (BMI) strata (8.9%, 46%; p < 0.0001), stratified multivariate analysis was subsequently performed. Among nonobese (BMI <30) gravidae, frequency of preeclampsia was significantly higher among women with OSA (adjusted odds ratio = 6.58, 95% confidence interval = 1.04, 38.51; p = 0.035). Among the obese (BMI ≥30) gravidae, infant birth weight ratio (or birth weight by gestational age) was higher with OSA + screening than OSA - (1.099 versus 1.035; p = 0.04), and this association remained significant after adjustment for potential confounders (p = 0.05). OSA prevalence increases significantly among obese gravidae, raising concerns for the overall validity of commonly employed screening measures in pregnancy. Nevertheless, OSA status continues to exert an independent influence, as obese and nonobese gravidae are at increased risk for a limited number of adverse perinatal outcomes in multivariate models.

Rate of wound complications with enoxaparin use among women at high risk for postpartum thrombosis.

OBJECTIVE: To estimate the rate of wound complications associated with protocol-driven postcesarean enoxaparin thromboprophylaxis. METHODS: After implementing an Institutional Clinical Practice Guideline for postoperative cesarean delivery thromboprophylaxis among at-risk gravid women (older than 35 years of age, body mass index greater than 30 kg/m2, or both), data on all cesarean deliveries over the first 23 months of guideline implementation were extracted and analyzed. Primary (wound hematoma, separation, or dehiscence) and secondary (venous thromboembolism) outcomes were compared in stratified and multivariable models controlling for potential confounders. RESULTS: Over 23 months, 2,509 cesarean deliveries were performed. A total of 1,677 (68%) gravid women met criteria for thromboprophylaxis; 653 received enoxaparin per protocol ("cases"), and, at the discretion of the ordering physician, 1,024 did not (at-risk, protocol-noncompliant "controls"). Cases differed significantly by virtue of maternal age, body mass index, and diabetic status. Univariable analysis subsequently revealed a higher rate of wound separation (6.8% compared with 3.6%, P=.003), rehospitalization (2.1% compared with 0.8%, P=.017) and composite score (8.9% compared with 4.8%, P=.002) among protocol-compliant cases, but no increased risk of wound hematoma (P>.06). In multivariable analysis, adjusted odds ratios continued to reveal an association between enoxaparin use and wound separation (OR 1.66, P=.04) as well as higher composite score (OR 1.69, P=.01). However, among the protocol-noncompliant controls, a nonsignificant increase in the rate of venous thromboembolism occurred. CONCLUSION: In our series, prophylactic enoxaparin use among at-risk gravid women undergoing cesarean delivery was accompanied by an increased risk of wound separation. LEVEL OF EVIDENCE: II.

Prospective trial on obstructive sleep apnea in pregnancy and fetal heart rate monitoring.

OBJECTIVE: Obstructive sleep apnea (OSA) involves episodic nocturnal apneas. Using polysomnography, we examined the predictive capacity of screening questionnaires (Berlin) in pregnancy. Incorporating simultaneous fetal heart rate monitoring (FHM), we examined the association of maternal apnea with FHM abnormalities. STUDY DESIGN: We enrolled 100 pregnant women at 26-39 weeks of gestation with OSA screening and baseline data ascertainment who underwent polysomnography and FHM for > or =3 hours. The relationship between maternal characteristics, OSA, and FHM was explored with multivariate analyses that were controlled for potential confounders. RESULTS: When compared with polysomnography, sensitivity and specificity by Berlin screening was 35% and 63.8%, respectively; the snoring component of the Berlin correlated better with oxygen desaturation <95% (P = .003). Body mass index was a significant confounder (r(s) = 0.44; P < .0001). No association was observed between FHM abnormalities and OSA parameters. CONCLUSION: In pregnancy, the Berlin questionnaire poorly predicts OSA. It is unclear whether fetal compromise during maternal apnea is a mechanism in OSA that is related to pregnancy outcome.