← Dr. Chapa’s OBGYN Clinical Pearls 
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It is vital to have good sleep, hygiene and. Yeah, kind of preaching to the choir there. Because I gotta be honest, I mean, this is not me. I mean, if I can get a good five to six hours of sleep a night, that's great. And I know that's terrible, but I'm just being real. The truth is, is that adults really do need like 7 to 9 hours according to the data of uninterrupted, good, deep, restful sleep. And I don't know if we do that. I don't know a lot of people do. I don't know if a lot of people do that because, you know, we toss and turn or we get up to go to the restroom, or you get up and you got to do the mandatory social media check, don't do that, that's terrible. Or whatever. But, but ideally, having good restorative sleep is vital to let your body reset itself, let the brain kind of, you know, kind of decompress. You know, there's been experiments that don't do them anymore, but they used to do, you know, these prolonged hours, you know, going on days of sleep deprivation. And they stopped those studies because, man, I mean, they literally wig out. I mean, the brain goes haywire because every good, well designed machine needs its downtime. I mean, you gotta turn off your laptop, phone should power down every once in a while. You gotta let them rest, okay? Same thing with the body and the brain. Now that's what we're gonna talk about in this episode. Because on September 16, 2025, out of Jama Network, there's a new study that came out which is not a prospective study, it's not an rct, it's not a multi center site site study, but it's still good. Although it's got some limitations because it's a data mining study. And you know, we've talked about this before, some things you got to do that, like just pull out, you know, ICD 9 or ICD 10 codes and take a look. But there's a lot, a lot of limitations. With that, and that's what was done in this study. The title of this JAMA Network open new publication is Ischemic Placental Disease and Severe Morbidity in Pregnant Patients with Sleep Disorders. Now let me say that again. Ischemic Placental Disease and Severe Morbidity in Pregnant Patients with Sleep Disorders. Now, if you listen to the show for some time, you may remember, wait a minute, didn't we cover sleep disorders in pregnancy some time ago? The answer is yes, we totally did. Two years ago, guys, two years ago we talked about this. Now we talked about this in one part of what this study concentrated on, but not in the second. So let me explain. In this new cross sectional retrospective observational study, they looked at codes ICD9 and ICD10 and then tracked out outcomes, what happened when these patients delivered, and looking for adverse maternal outcome and fetal outcome based upon a history of insomnia or obstructive sleep apnea. And that's what we covered two years ago on this show. In May of 2023, we released an episode called OSA obstructive sleep apnea. Time to screen. Because the data was pretty clear that in addition to all of the 1200 other screening questionnaires that we ask our pregnant patients while they're pregnant, and we should do that, we should ask things about domestic partner abuse, home safety, food insecurity, their depression scale, we need to do all of that. But we should potentially ask about obstructive sleep apnea, especially in high risk patients, meaning those with an obese bmi. Okay? Because obstructive sleep apnea is, without a question, linked to adverse pregnancy outcomes like preterm birth, small for gestational age, birth weights, fetal growth restrictions, hypertensive disorders of pregnancy and gestational diabetes because the body is under this chronic oxidative stress, this high physiological stress state with obstructive sleep apnea. So you got to go back and listen to that. In May of 2023, then two months after that, in July of 2023, a separate publication came out from the Society of Anesthesia, the Society of Sleep Medicine, the Society of Obstetric Anesthesia and Perinatology, which was a consensus guideline on, quote, the screening, diagnosis and treatment of obstructive sleep apnea in pregnancy, end quote. Guys, that was two months after we first released that in May of 2023. So we talked about this. The short answer is yes. Ask patients, especially those with high risk BMIs, about obstructive sleep apnea while pregnant and it is absolutely safe to Use CPAP in pregnanc. Just unclear if that's going to prevent some of those obstetrical adverse events. So the question is, well, then why do it? Well, do it because it's better for the body, period. It's just good for overall body wellness, to protect the heart and decrease some oxidative stress. But it's unclear if CPAP in pregnancy is going to reduce significantly those specific perinatal adverse issues. But without doubt, the consensus statement from July of 2023, which we covered at that time, says, yes, CPAP, even though we don't have a lot of data, definitely advised for obstructive sleep apnea in pregnancy. So we know that that's the part of this new publication that just came out on September 16th that is not new. But what is new is that these authors included the much more common sleep disturbance of insomnia. And so, guys, here's where I'm getting at. And we're going to do this very quickly. We gotta ask patients, especially at that first intake, hey, how do you sleep at night? And then again, maybe in each trimester, because we know that sleep disturbances in general tend to increase the more the patient becomes uncomfortable, as the abdomen grows harder to find a proper position. And so in general, sleep disturbances increase per trimester. We gotta ask them, because insomnia, we now have data, even though it's limited, even though this is retrospective, in a data mining study, insomnia, according to this brand new publication, not just obstructive sleep apnea, but even insomnia just by itself is also linked to some increased perinatal morbidity. So we're going to get into this here, okay? Now, even though the title says ischemic placental disease, that's the concept, that's the theory of what is happening with oxidative stress at the placental level is even though this did not include any pathology, histological samples, right? This didn't look at what the pathology of the placenta was. This just looked at the specific outcomes from the pregnancy, like DIC or venous thromboembolic event, bleeding, hysterectomy, preterm birth, the typical outcomes that people code for at delivery. So this did not include placental histology. So what is not new from this publication from September 16, 2025, is that once again, it proved what we said two years ago, two years ago, that obstructive sleep apnea is bad and insomnia is also bad, but not to the degree that obstructive sleep apnea is because obstructive sleep apnea is a true breathing abnormality. Okay, so that's where we're going to go. We're going to talk about this very briefly here. And you got to go back to May of 2023 and July of 2023, when we talked about obstructive sleep apnea and all the data behind why that's bad in pregnancy, even though there's no one scale that's validated for use in pregnancy. And we talked about the Berlin Scale, there's something called the Stop Bang Scale, there's all these other questionnaires there, but none of them are really that valid in pregnancy. The best way to screen for OSA in pregnancy is ask the patient, hey, do you get. Do you wake yourself up in the night with your own snoring? Or in the morning, does your partner say, you gotta do something about that blowhorn that's in your nose when you're sleeping? Because you're keeping everybody in the house awake? Ask, what do people say about you when you're sleeping? That's the easiest way. Not very scientific. But since no official scale has been validated for use in pregnancy, for osa, just using historical background can be okay. And then pushing the patient, of course, for a true definitive testing in the sleep center to make the diagnosis, because that's very important. So we're going to talk about the influence of insomnia on pregnancy outcomes. So ob, you need your Z's. That's what we're going to get into here. And we're just going to touch briefly on something that is not mentioned in this new publication, but it is mentioned in a separate meta analysis that is closely tied to this and it has to do with circadian rhythms. Okay, so let me just set the stage here very briefly. Insomnia by itself. So not sleeping at night is overall bad because you get that oxidative stress. Not to the same degree as osa, but still you need to get good sleep, you need reparative sleep. Okay? Restorative sleep. So briefly tied into that is this next question. And I know this is going to freak out our residents and physicians who are pregnant and work at night, but there is data that night shift working and working, when you flip your circadian rhythm that also is mildly to moderately associated with several adverse pregnancy outcomes. Just like insomnia and just like osa, mainly preterm birth, gestational hypertension, preeclampsia, gestational diabetes, and some small for gestational age newborns, there are all related Guys, so there's three things in this car that are driving together, okay? Night shift working, which is not in this publication, but I'm just throwing that in there as a bonus. That's a freebie. Night shift working, insomnia and obstructive sleep apnea. Now, the good news is for the night shift part is that there's no universal mandate right now that says if you're pregnant, you cannot work night shift. I mean, you're just doomed. That's not the case. The odds ratios here, thankfully, are still in the 1 point X range. In other words, the odds ratios are like 1.2 or 1.3, which is a 20 or 30% increase above baseline, which is significant. I'm not minimizing that. But thankfully, they're not two or above in terms of relative risk. So as of right now, according to a meta analysis that looked at night shift working, because you flip your circadian rhythm, there's just not enough data to say that you cannot recommend universal restriction of night shift work during pregnancy. What is recommended is if you flipped your circadian rhythm, then when you get home, you gots to go to bed, you got to turn off the phone, you got to tell your family, I'm sorry, I love you, I really do. But especially during pregnancy, I've got to go down, I've got to shut my system down, got to turn that. I got to reboot myself because I gotta let that body rest. Okay? So again, to be very clear, this new study from JAMA Network Open did not touch on night shifts, but it's intimately related to sleep hygiene. That's why I'm introducing this. So the last meta analysis that looked at this at night shift work said, hey, there's something we need to be aware of. Potentially does increase preterm labor small for gestational age because your circadian rhythm is all just jacked, okay? And your body's kind of freaking out a little bit. But quote, there is insufficient evidence to recommend universal restriction of night shift work in pregnancy, but individualization of risk assessment is warranted, especially for those with additional high risk factors for adverse outcomes. End quote. In other words, if. If you are a G4 P3 and each of the three previous deliveries were all preterm, and I mean, like, you know, not late preterm, but like real preterm, 30, 32 weeks or whatever, and you're working night shift, that's potentially a modifiable issue. Maybe asked to not do so many night shifts, but again, that's not the focus of this one, I just wanted to tie that in because that's tied to the altered circadian rhythm that is part of the insomnia problem. Everybody with me? Okay, so again, just to be clear, the JAMA Network open new publication that we're about to summarize when we get out of the intro and is not talking about night shift, it's talking about insomnia and osa. And I'm going to focus on the insomnia part because obstructive sleep apnea we already talked about two years ago when we were ahead of the curve. How about that? So, again, podcast family, that's where we're going as a good reminder that sleep hygiene is vital. Vital for all of us as our bodies reboot during restorative sleep. I think I've set it up enough. Let's get out of the intro and we'll be right back in just a moment. Tired of all the spin in women's health education? Yeah, so are we. This is Dr. Chapa's OBGYN no Spin podcast. Race the rudders. Raise the sails. Race the sails. Captain, an unidentified ship is approaching. Over. Roger, wait, is that an enterprise sales solution?
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You know, I really went back and forth whether we're going to cover this article or not, because it's got a lot of limitations. Right? It's a data bank search using ICD9 and ICD10 code. Do we know if people code things wrong? That's the info that you're using. And so there's a lot of selection bias and recall bias and incorrect coding that goes into this. It's retrospective, it's observational. So we don't. This is not saying absolutely that insomnia equals bad outcomes and you're doomed. It's just associations. We're just talking about it. Just like osa. These are associations. It's. It's definitely not helpful. We know that in. In no study does it say, man, you need to have more insomnia. I mean, you're sleeping way too much, bro. You, you know, wake yourself up in the middle of the night a couple of times. Okay, nobody says that. So we know it's not helpful. The degree to which it's not helpful and these odds ratios have to be taken with a grain of salt because it, it's data mining and it's, and it's retrospective. Okay, but before I go into this brand new and again we're going to do this quick, remember I'm into my new commitment to telling you what you need to know. And the short answer is three things. Ask about sleep hygiene screen for OSA as we mentioned two years ago, especially in those patients who are obese. And number three, even though they may escape osa, ask about insomnia and potentially their night shift work and tell them, look, you just got to take care of yourself. That includes good hydration and de stressing mindfulness when you get home, especially from working, you know, 12 hour shift at night. You got to, you got to have your alone time and go to bed because sleep hygiene is a big deal. And if you want to know that reference or read more about the reference on night shift and pregnancy that actually was out of 2019 in the Gray Journal, the American Journal of OB GYN. The title was the impact of Occupational Shift Work and Working hours during Pregnancy on, on health outcomes, the systematic review and meta analysis. That was 2019 in the gray journal. Again, I'm not going to focus on OSA even though knowing that it is a continuum. So night shift has the kind of, you know, the lowest risk for harm. Then comes insomnia as the next ladder rung up the ladder. And then OSA seems to be your most problematic because OSA isn't just behavioral, it's a true breathing problem. Okay. That's apnea. So that, that tends to be the worst as we put these things together. Okay. So this new study from Gemma Network Open was a cross sectional study out of California. This was only singletons. And unfortunately, I mean it, some things you have to do like this because it's very hard to do this prospectively. So some things you got to go to a, to a, a database and just mine the data and it's okay. But it did use ICD 9, ICD 10 codes. And so you know, again, crappy things that they put in. That's the data that you're going to use. But some things you got to do in this style. So they want, wanted to look at this in this cross sectional interval to see if reported insomnia and OSA was linked to some adverse pregnancy issues. You being severe morbidity. And we're getting just in a minute that includes, you know, small for gestational age, preterm labor, even bleeding, thrombotic risk and what this actually meant for patients who have not just OSA but insomnia. So the short answer is, while OSA we know is not good, insomnia, and this is the new part, insomnia also was not good. So compared to patients without insomnia or obstructive sleep apnea, the adjusted relative risk, that's called the ARR of any placental insufficiency thing, okay, was about 1.42. Now, I know what you're thinking, well, that's not that bad. No, it's really not. And that's why I said, thankfully, the Overall risk was under 2. But when they breaked it down for the specific things that they found, that's where the. The adjusted odds ratio did cross, too. I'm gonna get into it in a minute. But the overall adjusted ratio for some kind of adverse issue was 1.42 for insomnia. And as you would think, because I said this, a little bit worse, with obstructive sleep apnea, the overall risk of something potentially being bad was 1.57. Okay, now, when we break down the specific issues of harm, yeah, even insomnia by itself did have a significant risk for some severe morbidity. Now, these numbers are scary, but remember, these are relative risks, and the true absolute number is very small, still low. So even a twofold risk, which is important, is still an absolute number. That's not all that big. But let me read you this, because this is pretty scary just for those with insomnia, okay? The overall adjusted risk ratio for things like disseminated intravascular coagulation, that is 2.38 for some kind of cerebral vascular disorder, 4.23, sepsis, 2.6, shock, 3.61. These are relative risks, okay? A thrombotic embolism, 3.72, and even hysterectomy had an increased relative risk of about 3.02. The point is, what? Even insomnia, guys, is not benign. Now, I know those numbers are scary, and they are, and we need to respect those. But remember, limitations, data mining, and the absolute number is still pretty small. But compared with patients without either sleep disorder, the adjusted risk ratio was higher for patients with insomnia than it was for obstructive sleep apnea. For those specific, disseminated intravascular coagulation, puberopsepsis, cerebrovascular disorder, shock, thromboembolic embolism, and even hysterectomy. And now a word from our sponsor podcast family. I am extremely thankful and grateful to have this New personal corporate sponsor partnering with our show. That's right. It's unique to the Choppa Podcast community. I want to introduce you to a product that I use and I love. I use this every day. It is called the Strong Coffee Company. Strong Coffee Company. Now, not strong as in the amount of caffeine, but strong in what is in it. Strong actually stands for striving to reach our natural greatness. This is not your average cup of coffee. You can get that anywhere. This is coffee plus collagen, coffee plus protein, coffee plus L theanine and adaptogens. 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So the author's conclusions and relevance was in this cross sectional study of singleton live births, pregnant women with insomnia or obstructive sleep apnea were at increased risk for ischemic placental disease, significant morbidity and preterm birth compared with those without sleep disorders. Further study is needed to determine the biological mechanisms for these risks and whether early identification and targeted preventative interventions may improve pregnancy outcome. End quote. So of course more study is needed. But it just makes sense, doesn't it? I mean, if the body doesn't have a chance to have restorative sleep, then of course oxidative stress would be higher and these adverse issues would rise just as they do with obstructive sleep apnea. But it seems to be a continuum of risk, with the lowest risk being this night shift issue, which again was not included in this particular publication. Just thrown down, threw that in there as a freebie. Then comes insomnia with some real significant potential morbidity there, according to this limited study. That's retrospective and then the worst being obstructive sleep apnea, since that is a true breathing abnormality. Remember, that's apnea and that's bad. So this is something that we should tell patients and it's again, not that they should restrict nighttime working, but that they need to have appropriate time to recoup that rest so their body can try to reset because circadian rhythm that's thrown off kilter can have some consequences. But just to be clear, I am not saying do not work if you're pregnant at night. I don't want anybody's employer coming after me. That's not what I'm saying. I'm saying that there is evidence that night shift work without a doubt has mild to moderate increase in some adverse issues because it's tied again to altered sleep which is tied back to this altered circadian rhythm. Right. Your cortisol is all off. Normally, cortisol peaks in the early morning hours, but if you've worked all night, your cortisol is all, you know, haywire. So all of those things have to do with pregnancy outcomes. So what's the take home message here? Very easy. Ask patients about sleep. Ask patients about obstructive sleep apnea. Ask them if they do work during the night, do they stay hydrated, do they have mindfulness, do they try to recoup that balance so that their body can reset and have restoration? That's it. So we've covered this new publication from JAMA Network Open that was officially published online on September 16, 2025. The title is Ischemic Placental Disease and Severe Morbidity in Pregnant Patients with Sleep Disorders. Even though we covered the obstructive sleep apnea part two years ago, guys, we're ahead of the curve. At that time two years ago we covered this. This now has a new added information that insomnia isn't good either. Now the other issue is that. And we're going to do this and we're going to wrap this up. Ways to treat insomnia, guys, are pretty easy. You know, melatonin can be useful. We have a whole episode on melatonin in pregnancy that overused, has some concern for neurodevelopment of the child, especially because, you know, neurons are firing and developing, but in appropriate use every once in a while. Totally safe in pregnancy. So there's nothing wrong with melatonin, but it shouldn't be abused, of course, and try to use it only when necessary. Relaxation technique seems to help. Behavioral therapy, Believe it or not, cognitive behavioral therapy. There is a specific CBT for insomnia called cognitive behavioral therapy. Insomnia, that's good relaxation, like magnesium. Taking magnesium sulfate bath, that's called Epsom salts to, to help relax the body. All of those things are perfectly safe, as is melatonin when used correctly. Okay, so again, I just found this interesting that it's not just obstructive sleep apnea, that insomnia itself also can be potentially tied to adverse pregnancy issues. Although the relative risks here were kind of concerning, they are limited based on its data capture and the study nature of this publication. So I think we've done what we're supposed to do. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Now go get your rest on at night when you're home so you have better sleep hygiene and we'll see you at another episode on the no Spin podcast. We'll see you next time. Podcast Family, we're thankful for all of the support that you've given us throughout the years. This has been the OBGYN no Spin podcast. We'll see you on the next episode. Sam.