Obstructive Sleep Apnea (OSA) in Pregnancy: Current Evidence and Research Opportunities

Hongzhao (Joe) Ji, MD, and Enze Ma, MD, on behalf of the Sleep Disorders Committee

Sleep-disordered breathing (SDB) is a spectrum of disorders that range from snoring to total airway collapse, which can subsequently result in hypoxia and sleep fragmentation. Patients can experience daytime sleepiness, fatigue, and a variety of downstream health consequences, such as hypertension and insulin resistance.

Obstructive sleep apnea (OSA) is the most widespread disorder within the SBD population, affecting nearly one billion adults worldwide, with roughly 425 million suffering moderate to severe cases. In the United States, estimates suggest as many as 83.7 million adults have OSA, almost 32% prevalence. In the pregnant patient, pre-gestational OSA affects roughly 5-9% of women, but recent studies have shown that this increases to 20-25% by the third trimester (Farid, 2024; Poletti, 2025; Facco 2014; Facco 2017). Despite the surge in prevalence of OSA among pregnant patients, the management of OSA in pregnancy remains an under-discussed problem in otolaryngology.

Several physiologic changes during pregnancy contribute to higher risk and incidence of OSA. Gravid uterine growth displaces the diaphragm, reducing functional residual capacity (FRC) by 20%-30% (Farid, 2024; Valverde-Pérez, 2024). Rising estrogen levels in the body induce nasopharyngeal mucosal edema and hyperemia, thereby narrowing the airway and increasing upper airway resistance (Ansari, 2025; Lawlor, 2023). This may also contribute to edematous and vascular mucosa in the larynx and supraglottis (particularly in late pregnancy) which can result in increased bleeding risk or difficulty with instrumentation and intubation (Lawlor, 2023). Mallampati scores increase in overall severity by 34% during gestation (Farid, 2024). Finally, as in nonpregnant patients with obesity, increased accumulation of adipose tissue during gestational weight gain, particularly in the anterior neck, also contributes to OSA risk.

The maternal and fetal outcomes from OSA in pregnancy have been well studied. Gestational OSA has been linked to higher nocturnal blood pressure and daytime systolic blood pressure (Sanapo, 2024). OSA in pregnancy has been shown to be an independent risk factor for preeclampsia, eclampsia (Ansari, 2025; Tang, 2025), preterm birth, low birth weight, and NICU admission (Ansari, 2025; Liu, 2019). There is emerging evidence that links OSA in pregnancy to lower cognitive and language development in children by the age of 3 (Takenouchi, 2025).

Recent studies have investigated the screening and diagnostic frameworks for OSA in pregnancy. Traditional questionnaires like the Berlin, Epworth Sleepiness scale (ESS), and the STOP-BANG often yield false positives due to confounding normal pregnancy fatigue (Farid, 2024; Liu, 2019). A newer model, proposed by Facco, uses four variables: snoring, hypertension, age, and BMI. This has been shown to have 86% sensitivity (Farid, 2024). In fact, patients with habitual snoring >3 nights/week are four times more likely to have OSA (Farid, 2024). However, this model has yet to be validated in large, multi-institutional studies. A comparative meta-analysis emphasized the performance of this model in predicting pregnancy-related OSA, but it also highlights some key limitations, including high risk of bias and limited evidence in detecting patients with mild to moderate OSA (Farid, 2024; Siriyotha, 2021).

Diagnosing and Treating OSA

Polysomnography remains the gold-standard for diagnosis of OSA. However, given its complexity and higher costs, it is not always feasible, particularly in patients who may not have access to an in-house sleep laboratory. Home sleep apnea tests have become more prevalent in the diagnosis of OSA, as they offer a more convenient and cost-effective method for diagnosis. Some newer, wearable devices on the market have demonstrated diagnostic test accuracy, with over 90% accuracy when compared with PSG (Clements, 2024). Newly available devices can provide extremely low-cost studies by collecting single sensor data supported with artificial intelligence, suitable for screening or long-term monitoring (Retamales, 2024).

First-line therapy for gestational OSA is continuous positive airway pressure therapy (CPAP), which reduces gestational hypertension risk by 35% and preeclampsia risk by 30% (Lee, 2024). In-office turbinate surgery or polypectomy under local anesthesia may be used to improve nasal patency and CPAP compliance, particularly as this reduces the need for general anesthesia.

Currently, limited data is available regarding the implications of prior sleep surgery on patients with OSA diagnosed prior to gestation. In general populations, uvulopalatopharyngoplasty has a 40%-50% success rate, maxillomandibular advancement 80%-90%, expansion sphincteroplasty 80%, and hypoglossal nerve stimulator 75%-80% (Tang, 2025; Walker, 2025; Pang, 2024). Virtually, no published studies have investigated whether a history of tonsillectomy or palate surgery reduces incidence for gestational OSA. Similarly, no published studies are available regarding hypoglossal nerve stimulator performance in the context of pregnancy.

A critical data gap exists on the safety or outcomes of sleep surgery interventions for OSA during pregnancy. This lack of data is understandable, as elective surgical interventions during pregnancy carry significant risk. However, a patient identified as having significant gestational OSA could seek surgery after delivery, with the goal of optimizing future pregnancies. Future research should prioritize several key areas in the screening and treatment of gestational OSA.

There is an urgent need for a validated, pregnancy-specific screening tool and diagnostic criteria, as current validated OSA screening tools lose efficacy in pregnancy. Prospective studies are needed to determine whether high-risk patients might benefit from early intervention and prevention of gestational OSA. There is also little published data on mandibular advancement devices or other such oral appliances and their efficacy on OSA during pregnancy. Health disparities also warrant attention, as socioeconomic status, race, and access to medical services may influence both diagnosis and treatment adherence, emphasizing the need for inclusive, multicenter research.

OSA in pregnancy is increasingly prevalent and carries significant implications for maternal health and fetal development. Critical research gaps remain in the diagnosis and screening, as well as the safety and efficacy of interventions (surgical or otherwise) in this population. Future work should prioritize pregnancy-specific diagnostic tools, longitudinal outcome studies, establishment of OSA treatment prior to pregnancy, and inclusive, multi-center research to guide evidence-based, multidisciplinary care.

References

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