![]() 28 hypothesise that sleep loss may be a result of stress as well as a stressor itself, therefore affecting both the hypothalamic-pituitary-adrenal axis (and possibly fetal exposure to stress hormones) and the proinflammatory system which may in turn lead to adverse pregnancy outcomes. In the general population, there is increasing evidence that abnormal sleep patterns may be associated with adverse outcomes such as cardiovascular disease and mortality. 25 The insomnia symptoms questionnaire which is a 13-item self-report questionnaire was recently validated in 143 pregnant women at 12 weeks gestation. The insomnia severity index which uses seven items to examine the patient’s perception of insomnia has not been specifically validated among pregnant women. Each item is rated on a five-point Likert scale (0–4) and added up to a total score ranging from 0 to 28, with scores higher than 8, suggesting insomnia. 24 It includes seven items related to sleep disturbance severity, sleep-related satisfaction and the degree of daytime functional impairment, impairment perception and distress and concern-related to sleeping problem. The Pittsburgh Sleep Quality Index (PSQI) measures quality and patterns of sleep, 23 and it seems to be a reliable and valid tool in pregnant women. There are also sleep questionnaires available which are mostly used for research purposes and not necessary for the diagnosis of insomnia. 22 Overnight polysomnograms are rarely needed to diagnose insomnia. 21 Sleep diaries can also provide information about bedtime, sleep onset, nighttime awakenings, awake time, and subjective evaluation of sleep quality. ![]() ![]() 20ĭiagnosing insomnia and sleep disturbancesĪ diagnosis of insomnia is usually made via self-report sleep history. 19 Because progesterone and cortisol share binding sites on corticosteroid-binding globulin, this leads to higher free cortisol which may increase arousal. The higher levels of estrogen and progesterone are thought to contribute to insomnia and they also influence other hormones such as the cortisol-melatonin ratio. According to a cognitive model of insomnia, 17 in women who have tendency to worry or be anxious, some of the typical sleep changes in pregnancy may be expressed with a higher level of severity. 16 Why some women are more susceptible to insomnia is unclear. 9 Insomnia generally worsens right before labor because of the secretion of oxytocin, a wake promoting hormone. Sleep disturbances are more commonly associated with pre-existing and de-novo depression 13 – 15 as well as smoking. Pregnant women do not always see their sleep as being a problem 97% of 127 pregnant women surveyed reported symptoms of disrupted sleep, but only a third of them identified themselves as having a sleep disorder 11. 1, 8, 11, 12 Night waking is the most common sleep disturbance by the end of pregnancy almost all women are waking up 4, 8 and for longer periods of time 8. In the first trimester, the most common causes of poor sleep are nausea/vomiting, urinary frequency, and backache, while in the second and third trimesters the causes are fetal movements, heartburn, cramps or tingling in the legs, and shortness of breath. 9 In the last trimester of pregnancy, up to 69.9% reported difficulty in maintaining sleep, 34.8% described early morning awakenings, and 23.7% reported difficulty falling asleep. 5, 8 Up to 73.5% of women display some degree of insomnia at a median of 39 weeks, further classified as mild in 50.5%, moderate 15.7%, and severe in 3.8%. At the beginning of pregnancy, the incidence of insomnia is lower at 12.6% 7 and then increases as pregnancy progresses. 6 The rate of sleep disturbances also changes across trimesters, ranging from 13% in the first trimester, 19% in the second, and 66% in the third 1. During the first trimester, sleep increases (on average 7.4 to 8.2 h) and then decreases in the third trimester (6.6 to 7.8 h) as evidenced by surveys 4, 5 as well as polysomnography.
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