Sleep Conditions

What are sleep conditions during pregnancy?

Pregnancy disrupts sleep in several ways, due to changes in physiology, hormones, behavior, and the physical form of the body. This can lead to changes in quality and duration of sleep, resulting in various sleep abnormalities, including insomnia (difficulty falling asleep or staying asleep), awakenings during the night, and parasomnias (physical difficulties connected with sleep, such as restless legs syndrome), excessive sleepiness and narcolepsy (falling asleep all of a sudden when you dont want to sleep), disrupted circadian rhythms (sleep-wake cycle disturbance), snoring, and a problem with breathing during sleep called obstructive sleep apnea (OSA).

How common are sleep conditions in pregnancy?

Sleep conditions are fairly common, but the incidence differs depending on the conditions. Research suggests that the amount of time sleeping per day is lower during pregnancy compared with non-pregnant people. The incidence of snoring increases during pregnancy and throughout pregnancy, being more common in the third trimester. The same is true of restless leg syndrome which has been reported to increase from 17.5 percent of non-pregnant women to 31.2 during the third trimester of pregnancy. The quality of sleep also has been found to decrease during pregnancy and as pregnancy goes on. Insomnia is extremely common during pregnancy, with close to 80 percent of pregnant women suffering from insomnia. Narcolepsy occurs in 25 – 50 per 100,000 people. In women, narcolepsy typically appears between the ages of 15 25 years, so it is a condition that can co-exist with pregnancy.

 How are sleep conditions diagnosed?

Your doctor, or your therapist, go through your medical and sleep history to evaluate your sleep problem, using lists of criteria whose presence indicates insomnia disorder and other disorders affecting sleep. In the case of insomnia, if the sleep trouble occurs at least three nights per week and has been happening for at least three months, if the problem occurs even with enough time for sleep, and if the problem cannot be attributed to some other condition, then insomnia disorder is diagnosed. Alternatively, you might meet the criteria for a different disorder, such as obstructive sleep apnea (you stop breathing momentarily, which wakes you for a few moments without you knowing), or a circadian clock shift (your body does want to sleep once per day, but you are shifted to match the light and darkness of a time zone different from the one in which you live.) Diagnosis of narcolepsy depends on your history, but also on a test called a polysomnogram and another test called a multiple sleep latency test.

Do sleep conditions cause problems during pregnancy?

Yes, sleep conditions can cause problems. The most common pregnancy sleep condition, insomnia, for instance, puts you at risk of developing depression in the late 3rd trimester and after delivery. It also increases the likelihood of preterm birth, longer labor, and operative birth (cesarean section and instrument-assisted vaginal birth). Furthermore, insomnia at night makes you tired during the day with a tendency for day-time sleep (hypersomnia), which can lead to mood changes and interfere with your relationship with your partner.

Do sleep conditions during pregnancy cause problems for the baby?

Insomnia and other sleep conditions can affect the baby by increasing the chance of instrumented delivery and prolonged labor. Following birth, problems with sleep also can impact mother-infant bonding. By triggering depression during pregnancy, sleep conditions have been shown to harm the developing baby independently of any anti-depressant medication the mother may require as treatment.

What to consider about taking medications when you are pregnant:

• The risks to yourself and your baby if you do not treat the sleep condition
• The risks and benefits of each medication you use when you are pregnant
• The risks and benefits of each medication you use when you are breastfeeding

What should I know about using medication to treat sleep conditions during pregnancy?

With many sleep conditions, insomnia, for instance, medication is indicated only after non-drug strategies have been attempted and have failed. Once it is decided that medications are the best option, there are numerous choices as drugs vary greatly in their effectiveness and risks to the developing baby. Based on available studies to date, fairly safe sleep-inducing medications during pregnancy include the drugs chloral hydrate, eszopiclone, zaleplon, zolpidem, and diphenhydramine. We are more worried about a common group of medications called benzodiazepines. Certain drugs should be avoided during pregnancy, such as paroxetine, and in the first-trimester carbamazepine, lithium, and valproic acid as they can cause birth defects. Additionally, a host of other drugs are useful for insomnia during pregnancy, but only if a different condition is the main reason for using the drug. Certain antidepressants fall into this category (used in a depressed pregnant patient who also has insomnia), as do drugs given for psychosis and bipolar disorder (mood stabilizers).

Drug treatment for narcolepsy consists of stimulant medications and medications that promote wakefulness without acting as stimulants. Stimulants include methylphenidate and dextroamphetamine, both of which are also used to treat attention deficit hyperactivity disorder (ADHD). The main non-stimulant, wakefulness drug given for narcolepsy is called modafinil. This is a mixture of two chemicals that are mirror images of one another. The right-handed for of that drug, known as R-modafinil, is available by itself as a drug called armodafinil, which also can be given for narcolepsy. Other types of drugs, used specifically for the cataplexy element of narcolepsy, sodium oxybate, and certain anti-depressant drugs, including venlafaxine, fluoxetine, and clomipramine. Drug treatment usually is not initiated until after an attempt is made to manage the condition through sleep hygiene, meaning careful management of your sleep schedule and the habits associated with your sleep and sleep environment, but in most cases medications become necessary.

Who should NOT stop taking medication for sleep conditions in pregnancy?

If you are prescribed a drug that is considered safe during pregnancy, and if it works for you, there is no reason to stop the treatment. No pregnant woman who is being maintained on drug therapy for narcolepsy needs to stop treatment. Generally, the decision is made in consultation between the woman and her doctor based on a balanced assessment of the benefits and drawbacks of the drug. In some cases, patients and doctors will consider stopping drug treatment temporarily
as the time for labor and delivery approaches in order to reduce the chance that the medication will produce dependence in the newborn.

What should I know about choosing a medication for sleep conditions in pregnancy?

You may find Pregistrys expert reports about the individual medications to treat sleep conditions here. Additional information can also be found in the sources listed at the end of this report.

What should I know about taking a medication for sleep conditions when I am breastfeeding?

Potentially hazardous drugs to nursing infants include doxepin, which is given for depression combined with insomnia, and lithium, which is given when the insomnia is connected with bipolar disorder. Insomnia drugs that are fairly safe in lactating mothers include zaleplon, certain antidepressants, and some mood stabilizers, such as valproic acid and carbamazepine. 

All of the medications that are given for narcolepsy enter into breastmilk and also affect the brain. Consequently, women who require narcolepsy medication should give strong consideration to avoiding breastfeeding and choosing an infant formula with the help of the baby’s pediatrician. In the case of narcolepsy, the main factors that you must consider are the potential consequences of your being unable to obtain consolidated sleep, being able to function during what should be waking hours, and the severe consequences for you, the baby, and other people if there is a serious chance that you could fall asleep while driving. The fact is that you cannot be permitted to drive if your narcolepsy is not manageable, and not only that but it may not even be safe for you to walk up and down stairs, nor will it be safe for you to carry the baby.

What alternative therapies besides medications are there to treat sleep conditions during pregnancy?

The first-line treatments for most sleep conditions, including insomnia, sleep-wake cycle disturbances, and narcolepsy, are sleep hygiene and sleep education, which means that you are taught about how to take control of your sleep-wake cycle and directed to habits that promote sleep, such as using your bed only for sleep (as opposed to sitting/lying in bed to study and work or to watch television or videos), going to bed and waking up on a regular schedule, sleeping in dark, cool rooms, and avoiding blue, bright light prior to going to bed. Such light typically comes out from device screens, so if you must use a device at night, set the display to low intensity and comfort view that reduces or eliminates blue light that hits your eyes. Its also possible to find special glasses that filter out the blue components of light, but with or without the glasses you should avoid light that is very intense. If you cannot darken the room completely, a sleeping mask can be helpful too. Avoiding light is one aspect of stimulus control, which also involves avoiding caffeinated beverages in the later part of the day. Generally, it is recommended that people with narcolepsy, including pregnant women and new mothers with narcolepsy, sleep 7 9 hours each night, all at once (not divided into a few naps), falling asleep at the same time each night and waking up the same time each morning. You should avoid alcohol and during the daytime, you should also avoid large meals that may put you to sleep.

Along with sleep hygiene and stimulus control, there are various behavioral therapies. These make use of relaxation, sleep restriction, cognitive therapy, and cognitive-behavioral therapy.

What can I do for myself and my baby when I have a sleep condition during pregnancy?

It is important to manage sleep conditions with the same seriousness as we approach other conditions. You must seek treatment because your insomnia can affect your mood, your labor, and even your child.

Resources for sleep conditions during pregnancy:

For more information about sleep conditions during pregnancy, contact http://www.womenshealth.gov/ (800-994-9662 [TDD: 888-220-5446]) or read the following articles:

• Mayo Clinic: Sleep During Pregnancy
• National Sleep Foundation: https://sleepfoundation.org/