1. Erwin, Andrea M. PhD, RN

Article Content

Sleep is essential for our well-being, affecting our daily functioning and overall health. Unfortunately, sleep disturbances and/or disorders are common throughout pregnancy. A majority of women (66% to 97%) report sleep problems during pregnancy, resulting from the hormonal, anatomic, and physiologic changes necessary to maintain pregnancy. Sleep complaints are specific to each trimester, often increasing in frequency and severity as the pregnancy progresses.


In this article, we discuss common sleep-related issues and their consequences during the course of pregnancy, as well as patient management strategies.


Unstable architecture

Sleep architecture-the cyclical pattern of sleep across a typical night in a healthy adult-quality, and quantity are altered during pregnancy due to the daily rhythm and circulation of pregnancy-related hormones, physical discomforts, and psychological changes. These essential changes can lead to sleep disturbances or disorders, or further complicate preexisting sleep disorders.


Sleep-related disturbances may include:


* fatigue


* daytime sleepiness


* snoring


* restless sleep


* multiple nighttime awakenings


* vivid dreams or nightmares.



Sleep-related disorders may include:


* sleep-disordered breathing, such as obstructive sleep apnea


* sleep-related movement disorders, such as leg cramps and restless legs syndrome


* parasomnias, such as sleepwalking, night terrors, insomnia, and narcolepsy.



Consequences of interrupted ZZZs

Quality sleep is essential for maternal physical and mental functioning, as well as fetal development. Poor sleep quality is associated with adverse outcomes during and after pregnancy, such as maternal morbidity and mortality; impaired immunity; longer labors; higher rates of delivery by cesarean section; increased perception of pain and discomfort during labor; depression; and cognitive impairments, such as decreased concentration, memory, and work performance.


Poor sleep quality can also adversely affect fetal well-being. Sleep-disordered breathing, often associated with pregnancy-induced hypertension and gestational diabetes mellitus, can lead to maternal hypoxia and decreased cardiac output. This, in turn, increases the risk of premature delivery, intrauterine growth restriction, low Apgar scores, and infant mortality.


Management strategies

What can you teach your patients to improve sleep throughout their pregnancy?


* Lose weight before pregnancy as warranted and manage weight throughout pregnancy.


* Maintain a routine sleep-wake schedule.


* Drink plenty of fluids during the day and taper them off before bedtime.


* Engage in at least 30 minutes of physical activity daily.


* Eat a balanced diet with small, frequent meals and take daily prenatal supplements as indicated.


* Sleep in the left lateral position to improve maternal and fetal blood flow.


* Use support pillows to improve comfort.


* Elevate the head of the bed to reduce heartburn or snoring.


* Relieve nasal congestion.


* Avoid smoking; alcohol; caffeine; and spicy, acidic, or fried foods.


* Keep the bedroom dark and cool.


* Use the bed only for sleeping.


* Manage pain and discomfort as recommended by a healthcare provider.



Sleep tight

Healthcare professionals rarely discuss sleep complaints with pregnant patients; however, these complaints shouldn't be dismissed as an annoying but expected part of pregnancy. Effective management of sleep disturbances and disorders may improve pregnancy outcomes. Healthcare professionals should thoroughly evaluate sleep quality and quantity during office visits.


With early detection of sleep problems, we can intervene to prevent adverse outcomes. We have the opportunity to educate women about pregnancy-related sleep problems as part of their routine prenatal care, providing information about sleep hygiene and other symptom management strategies. Our goal is to promote the optimal health of our pregnant patients and their fetuses.


consider this

First trimester (weeks 1 to 13)

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Marie, a 25-year-old teacher, presents to your clinic 10 weeks' pregnant. She complains that she's tired all the time. What do you need to know about the first trimester? Let's review. Fatigue and daytime sleepiness are prevalent during the first trimester as a result of hormonal changes associated with pregnancy. Pregnancy-related hormones (such as estrogen, progesterone, prolactin, oxytocin, melatonin, cortisol, growth hormone, and relaxin) cause physiologic changes and affect both the sleep-wake cycle and sleep architecture. Sleep disturbances increase 1.4-fold compared with before pregnancy due to nausea and vomiting, urinary frequency, physical discomforts such as gastroesophageal reflux, altered appetite, and elevated anxiety.


Second trimester (weeks 14 to 27)


Marie is now 23 weeks' pregnant. She informs you during her routine prenatal visit that she's less fatigued now and has more energy during the day. She laughs that she keeps her partner up at night with her snoring. What does this tell you about the second trimester? Women acclimate to hormonal changes associated with pregnancy during the second trimester. Sleep disturbances and daytime sleepiness decrease, resulting in increased energy levels. At the end of this trimester, irregular uterine contractions, fetal movements, heartburn, and snoring begin to disrupt sleep.


Third trimester (weeks 28 to 40)


Marie has reached her 32nd week of pregnancy. She complains that she wakes up frequently during the night and feels tired during the day, despite taking daily naps. She states that she and her partner are cranky because she wakes them both with her snoring and moving around in bed. What do these symptoms tell you about the third trimester? Women report fatigue, restless sleep, multiple nighttime awakenings, and daytime sleepiness during the third trimester. Sleep-related disorders, such as sleep-disordered breathing and restless legs syndrome, increase during this trimester.




Dixon CL. Sleep deprivation and pregnancy related risks. Int J Childbirth Educ. 2014;29(3):62-65.


Ibrahim S, Foldvary-Schaefer N. Sleep disorders in pregnancy: implications, evaluation, and treatment. Neurol Clin. 2012;30(3):925-936.


Izci-Balserak B, Lee K. Sleep disturbances and sleep-related disorders in pregnancy. In: Kryger MH, Roth T, Dement W, eds. Principles and Practice of Sleep Medicine. 5th ed. Elsevier; 2011:1572-1586.


Mindell JA, Cook RA, Nikolovski J. Sleep patterns and sleep disturbances across pregnancy. Sleep Med. 2015;16(4):483-488.


National Institute of Neurological Disorders and Stroke. Understanding sleep.


National Sleep Foundation. Pregnancy and sleep.


Palagini L, Gemignani A, Banti S, Manconi M, Mauri M, Riemann D. Chronic sleep loss during pregnancy as a determinant of stress: impact on pregnancy outcome. Sleep Med. 2014;15(8):853-859.


Tauman R. Maternal sleep and fetal outcome.


Won CH. Sleeping for two: the great paradox of sleep in pregnancy. J Clin Sleep Med. 2015;11(6):593-594.