Disturbed Sleep & Problematic Pregnancies

University of Pittsburgh nurse researcher hypothesizes connection between poor sleep quality, depression and immune system disruption

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The first question at any postpartum checkup always surrounds sleep. New research suggests these conversations need to occur during pregnancy visits as well.

According to Michelle Okun, PhD, University of Pittsburgh, sleep needs to become part of the clinical realm in obstetrical care.

"There's very little literature on poor sleep in pregnancy but what's out there says it puts the immune system in hyper drive when it's not necessary and destroys healthy tissue," she explained.

Okun's study was published in the journal Psychosomatic Medicine last summer, stating that both the quality and quantity of sleep can contribute to lower birth weights and other complications. Women with depression also are more likely than non-depressed women to suffer from disturbed sleep and to experience immune system disruption and adverse pregnancy outcomes.

"There is a dynamic relationship between sleep and immunity, and this study is the first to examine this relationship during pregnancy as opposed to postpartum," added Okun.

Cytokine Connection
Okun's study revolves around the fact that shortened sleep causes an overproduction of cytokines, which act as signal molecules that communicate among immune cells.

Just as there are marked reductions in cytokine concentrations after a nap or recovery period, Okun theorized that the opposite is true when sleep is evasive. The bulk of causal evidence is derived from short-term studies that show sleep deprivation, disruption or poor quality can initiate aberrant reduction of and delays in nocturnal release of sleep-associated cytokines.

Her earlier research proved both circulating and stimulated levels of proin ammatory cytokines are higher among pregnant women with insomnia-like symptoms compared with both pregnant women who have shorter periods of wakefulness at night and non-pregnant women.

While cytokines are important for numerous pregnancy-related processes, excess cytokines can attack and destroy healthy cells and cause destruction of tissue in pregnant women, thereby inhibiting the ability to ward off disease. For expectant mothers, excess cytokines also can disrupt spinal arteries leading to the placenta, cause vascular disease, lead to depression and cause pre-term birth.

In Okun's most recent study among pregnant women with the lowest sleep quality before 20 weeks gestation, the risk of delivering pre-term was increased by 30-40%. The odds of gestational diabetes, maternal morbidity and low birth weight were amplified as well. While infection accounts for half of these adverse outcomes, researchers discovered that behavioral processes such as disturbed sleep also may play a role, given the relationship between sleep disturbance and immune function. Furthermore, higher concentrations of inflammatory cytokines also are found in depressed individuals. At 20 weeks, depressed pregnant women have higher levels of inflammatory cytokines compared to non-depressed women.

The study population wasn't chosen haphazardly. By 30 weeks in pregnancy, a natural rise in cytokines occurs. Differences in cytokine levels between depressed and non-depressed women disappear at this time as well.

Sleep Interventions
Okun insists that the key is identifying disturbed sleep problems early in pregnancy to avert complications in the final trimester.

"If sleep impacts placenta development before 20 weeks, then we can reduce the impact of the negative behavior on physiology," she reasoned. "By the third trimester, it's too late to do anything."

As a starting point, she said guidelines need to be established on a prescribed amount of sleep during pregnancy.

Practitioners need to ask about sleep quality during checkup. Conversation starters can be as simple as, "how many hours of sleep do you get a night?" or "how do you feel about the quality of your sleep?"

As behavioral interventions to combat insomnia are often effective in non-pregnant patients, Okun suggested applying some common sense tips to the sleep deprived mothers-to-be.

"If anxiety is involved, talk about ways to reduce her anxiety," she advised. "If women wake for more than 20 minutes, have them move to another part of the house while still keeping the lights off. Equate the bed with sleep and sex only - no reading, no TV."

Exercise, positive health habits and mindfulness endorsements may have their place in the ob/gyn- or nurse-patient encounter, said Okun.

"It's my goal in life to get clinicians asking about sleep or encouraging patients to keep sleep diaries, if necessary," she said.

Moving forward, Okun plans to expand upon her finding on pregnant women with depression as well as the effect of naps and exercise. A sub-set of her study is the first ever to evaluate use of antidepressants and sleep in pregnancy. As it's possible to classify only one selective serotonin reuptake inhibitor (SSRI) at a time and each offers a different sleep mode, this would logically need to be a different study. But, Okun assured that SSRIs reduce cytokines.

"Our sample size is too small to offer a certain answer but the data we have is suggestive that women on antidepressants have better sleep and, therefore, better outcomes," she hypothesized.

Robin Hocevar is on staff at ADVANCE. Contact: rhocevar@advanceweb.com


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