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This preview shows page 1 - 3 out of 24 pages. QUIZ209 MANAGEMENT DURING PREGNANCYQuestion 1Why is the first prenatal visit usually the longest prenatal visit? Get answer to your question and much more Question 2A client at 32 weeks' gestation telephones the health care provider’s office asking if omeprazole 20 mg daily is safe to take as she is experiencing heartburn. When reviewingthe over-the-counter medication, the nurse notes a pregnancy category C listed. Which would be the nurse’sfirstaction? Get answer to your question and much more Question 3Why is a Papanicolaou test done at the first prenatal visit? Get answer to your question and much more Question 4The nurse understands that the maternal uterus should be at what location at 20 weeks' gestation? Get answer to your question and much more Question 5What is themosteffective way for a nurse to assess a woman's usual food intake during her pregnancy? Get answer to your question and much more Question 6The nurse is providing care for a pregnant client who has been given the necessary requisitions for laboratory work by the primary care provider. The client notices that the labtests include testing for HIV and other sexually transmitted infections, and expresses alarm, stating, "I don't understand why the doctor would suspect that I've got thesediseases." What is the nurse'smosttherapeutic statement? Get answer to your question and much more Question 7The nurse provides teaching to a client in the first trimester about food choices that will provide protein during pregnancy. Which food(s) will the nurse recommend? Select allthat apply.Question 8A client at 34 weeks' gestation reports difficulty sleeping at night. What will the nurse recommend? Get answer to your question and much more Upload your study docs or become a Course Hero member to access this document Upload your study docs or become a Course Hero member to access this document End of preview. Want to read all 24 pages? Upload your study docs or become a Course Hero member to access this document Tags Ectopic pregnancy, vaginal bleeding, early pregnancy, LMP Pak J Med Sci. 2016 Jul-Aug; 32(4): 1030–1037. Sleep disturbances are common in pregnancy. Insomnia is a frequent sleep disturbance experienced by pregnant women which can be primary or due to co-morbid conditions. The differential diagnosis of insomnia in pregnancy includes anxiety disorders, mood disorders, breathing
related sleep disorders and restless legs syndrome. Early interventions to treat the sleep disturbance are recommended to avoid adverse pregnancy outcomes. Management strategies include improving sleep hygiene, behavioral therapies, and pharmacotherapy. The risks of pharmacotherapy must be weighed against their benefits due to the possible risk of teratogenicity associated with some medications. We searched PubMed and Google Scholar
employing a combination of key words: pregnancy, sleep disturbances, Obstructive Sleep Apnea, Sleep disorders and insomnia. We included original studies, review articles, meta-analysis and systematic reviews in our search prioritizing articles from the last 10-15 years. Articles older than 15 years were only included if their findings had not been superseded by more recent data. Further selection of articles was done from bibliographies and references of selected articles. Sleep disturbances in pregnancy are common and cause considerable morbidity. Management includes a combination of non-pharmacological and pharmacological treatments carefully weighing the risks and benefits of each for the expectant mother and fetus. KEY WORDS: Insomnia, Obstructive Sleep apnea, Pregnancy Sleep
disturbances are common in pregnancy. A US National Sleep Foundation’s Women and Sleep Survey in 1998 found 78% of women reported disturbed sleep during pregnancy and 15% of women developed Restless Legs Syndrome (RLS) during 3rd trimester of pregnancy. Additionally, 15% of pregnant or recently pregnant women reported one weekday nap and 60% women reported at least one weekend nap. Sleep duration and quality related changes in pregnancy may be due to many proposed and
interrelated mechanism like hormonal, physiologic, metabolic, psychological and posture related changes. For example during first trimester, a rise in progesterone levels may cause excessive day time sleepiness, decreased muscle tone, increased risk of sleep apnea, snoring and sleep interruptions. Frequent trips to the bathroom, nausea and vomiting, pregnancy related discomfort like back pain, fetal movements and gastro-esophageal reflux can also impair the quality of sleep. Anxiety during pregnancy may be further amplified by concerns about labor, delivery and its outcome. Poor quality sleep is not only a core feature of prenatal, intra-natal and postpartum depression, but also a risk factor for mood disturbances in pregnancy. After child birth it becomes even harder for new mothers to have a good night’s sleep. Sleep disturbances affect health and quality of life and may also negatively influence obstetric outcomes. A recent study at
University of California, San Francisco found that women who slept less than 6 hours per night were more likely to have longer labor and were 4.5 times more likely to have a cesarean section. Both non-pharmacological and pharmacological interventions may alleviate sleep disturbances. This review is intended to provide practitioners with an understanding of sleep changes in pregnancy and guide them in rational approaches to their management. Sleep related problems are common during pregnancy including insomnia, RLS, sleep apnea, nighttime gastro-esophageal reflux disease (GERD), back pain, quickening and frequent nighttime urination. Sleep problems and changes in sleep patterns start during the first trimester of
pregnancy1 most likely influenced by the rapid changes in reproductive hormone levels. Levels of progesterone rise throughout pregnancy. At 36 weeks progesterone levels are 10 times greater than peak menstrual cycle levels. Women during first trimester take day time naps in part due to fatigue. In animal studies, progesterone administration has been observed
to have sedating effects, to reduce wakefulness, shorten the latency and increase the duration of non-rapid eye movement (NREM) sleep. Estrogen reduces the amount of Rapid Eye Movement (REM) sleep.2 Progesterone metabolites impact brain gamma amino butyric acid-A(GABA-A)
receptors2 which are thought to drive these sleep changes. In animal studies, estrogen selectively suppresses REM sleep3 an effect possibly due to increased brainstem nor-epinephrine
turnover.4 However, increased REM sleep has been observed in human studies of peri-menopausal women receiving estrogen replacement therapy,5 making it difficult to understand the specific effects of estrogen on sleep during human pregnancy. In an animal
model, total sleep time increases during pregnancy, with an early but transient increase in REM duration, a sustained increase in NREM sleep over the course of pregnancy, and increased diurnal sleep during late gestation.6 In human pregnancy, hypersomnolence is a common complaint during the first
trimester.7 Corresponding to this period of increased sleepiness, women surveyed about their sleep habits during pregnancy reported an average increase of 0.7 hours of sleep duration during the first trimester, compared to the pre-pregnancy period.8 Similarly, a
mean increase of more than 30 minutes of nighttime sleep was noted at 11 to 12 weeks of gestation in 33 women who underwent in-home polysomnography prior to conception and during each trimester of pregnancy.1 During first trimester Stage 1 of NREM sleep increases whereas stage 3 of NREM decreases and sleep efficiency decreases compared to the pre-pregnancy
period.1 Sleep during first trimester is also disturbed due to fatigue as well as nausea or vomiting.1 By late in the second trimester (23-24 weeks of gestation),
total night-time sleep time falls.1 There is an increased amount of stage 3 NREM sleep compared to the first trimester with a corresponding increase in complaints of interrupted sleep due to nocturnal GERD.9 During the third trimester, the
majority of women have sleep difficulties. Less than 2% report no nocturnal awakenings.8 There is reduction in the percentage of REM and Stage 3 NREM sleep and an increase in stage 1 NREM sleep.10 Despite increased wake time after sleep onset and reduced
nighttime sleep time compared to the first 2 trimesters, total sleep time normalizes or increases to approximately pre-pregnancy sleep level. There is no evidence of a shift in circadian phase (e.g. delayed sleep phase or advanced sleep phase) with melatonin levels showing a diurnal rhythm. A majority of women experience sleep problems in 3rd trimester with over 98% reporting nocturnal awakenings. There is a rise in Stage 1 NREM and reduction in Stage 3 and REM parts
of sleep. Despite these changes and reduced sleep time as compared to first 2 trimesters, total sleep time normalizes to almost pre-pregnancy levels. There is no evidence of changes in circadian rhythm with melatonin levels showing a diurnal rhythm. In 3rd trimester, sleep disturbances are due to general discomfort caused by backache, urinary frequency, fetal movements, GERD and leg discomfort. Sleep
problems increase in the first 6 months after child birth with total nocturnal sleep time of less than 6 hours.11 Sleep efficiency improves over time as the infant’s circadian rhythm matures. Women who breastfeed have more stage N3 sleep (third phase of NREM sleep) than those who do not, which could be attributed to prolactin’s effect on stage N3
sleep.12 There is shortened latency to stage REM sleep at 1 month postpartum, which could be attributed to progesterone returning to pre-pregnancy level or sleep loss in the postpartum period.13 Insomnia is defined both as a symptom and as a disorder. As a symptom this clinical condition is quite common in practice, however, as a diagnosis, insomnia has multiple defined sub-classifications in DSM 5 (Diagnostic and Statistical Manual-5th Edition)
(Table-I).14 Table-ISubclassification of sleep disturbances according to DSM-5.
A majority of women experience insomnia during pregnancy with rates as high as 80%.15 Insomnia is worse in the third trimester.15 A diagnosis is usually made by clinical history which includes screening for common sleep disorders seen in pregnant women. Because of the common co-morbid nature of insomnia, the DSM-5 recommends using the term “Insomnia disorder” instead of secondary insomnia since the term “secondary” suggests that treating the primary disorder or problem is all that’s needed to treat insomnia. Common pregnancy related complaints like back pain, nocturia, fetal movement, breast tenderness and leg cramps can negatively affect sleep quality and quantity.15 However, treating these problems does not necessarily mean that insomnia will automatically get better. Daytime effects of insomnia include hypersomnia, fatigue and mood changes. Insomnia can also negatively impact partner relationship and interfere with mother-infant bonding. Moreover, sleep disturbances in 3rd trimester are associated with increased perception of labor pain, longer labor and increased operative births. Patients with insomnia have high pro-inflammatory cytokines which is also seen in postpartum depression, preterm birth and other pregnancy complications. Clinicians should address the sleep disturbances promptly because it puts the pregnant women at higher risk of complications like depression in late third trimester or after child birth. Differential diagnosis of insomnia in pregnancyAnxiety disordersSleep disturbance assessment should include careful screening of primary mood disorders like major depressive disorder (MDD) or bipolar disorder or primary anxiety disorders like generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), panic disorder or obsessive compulsive disorder (OCD) because these conditions can present as prenatal insomnia. As with MDD, diagnostic criteria for conditions such as GAD may overlap with common symptoms of pregnancy including being easily fatigued, difficulty concentrating, emotional reactivity, and muscle tension. For the diagnosis of GAD, patients also manifest excessive anxiety and worry that is difficult to control for at least 6 months and cause clinically significant distress and impairment. Similarly, difficulty falling or staying asleep and restless sleep are included in the diagnostic criteria for PTSD but patients with PTSD also have other symptoms such as hyperarousal, increased reactivity, flashbacks, and avoidance of traumatic stimuli. Mood disordersAccording to DSM-5, sleep disturbances are an important feature of MDD. They are also central features of manic and hypomanic episodes which are an important consideration in evaluating pregnant women with sleep problems. Due to the overlap of symptoms of pregnancy with neurovegetative symptoms of depression, the diagnosis of mood disorders becomes very challenging. Clinicians can rely on several elements to diagnose primary mood disorder. For instance, pregnant women with depression experience anhedonia (diminished interest or pleasure in all or almost all activities) nearly every day. Other symptoms like psychomotor retardation, feeling of worthlessness, excessive or inappropriate guilt and recurrent thoughts of suicide are primarily experienced by pregnant women with depression. Moreover, assessment of time course, frequency and severity of symptoms can differentiate between pregnancy symptoms and symptoms of MDD. According to DSM-5, symptoms should not only occur for most days over a 2 week period but should also cause significant distress in social, occupational and other areas of functioning. Before considering a diagnosis of MDD, patient should be screened for a past history of hypomania or mania (days/weeks of expansive thought, decreased need for sleep, impulsivity, racing thoughts, talkativeness etc.). Pregnant women can present with MDD, but a past history of mania or hypomania would suggest Bipolar Disorder, leading to different pharmacological treatments like mood stabilizers before the postpartum period, a time with higher risk of recurrent mood episodes. Sleep Disorders
Untreated RLS increases risk of depressed mood, and RLS related sleep deprivation is linked to adverse effects like prolonged labor, heightened pain perception and discomfort during labor, higher rates of C-section, preterm labor and elevated inflammatory cytokines.24 Management of insomnia during pregnancyIt is important that clinician should inquire about difficulties in sleep initiation, maintenance or early morning awakening and understand environmental and behavioral factors. Obtaining a complete medical history including risk factors is pivotal for diagnosis and treatment and early intervention is recommended. Non-pharmacologic Interventions
Pharmacological Interventions (Table-III)Table-IIIPharmacological Interventions with Safety Profile.
HypnoticsIf non-medical interventions have failed for moderate insomnia during pregnancy antihistamines like doxylamine, which is safe in pregnancy, can be used.28 For pregnant women with more severe insomnia, treatment with a sedating antidepressant or sedative-hypnotic may be necessary. Commonly used sedative-hypnotics like Zolpidem have limited reproductive safety data which limits their use in pregnancy.29-31 BenzodiazepinesFor severe anxiety and insomnia benzodiazepines like lorazepam can be considered. Although earlier studies have shown increased incidence of cleft lip with their usage during pregnancy, recent studies have not found any association.32,33 A recent meta-analysis32 showed that the risk of major congenital abnormalities was similar in children born to mothers with anxiety and depression but without any drug exposure in the first trimester when compared to children born to mothers who received diazepam, temazepam, eszopiclone or other anxiolytic/hypnotics in the first trimester indicating that prescription of these drugs during early pregnancy may be safe in terms of risk of major congenital anomalies but further studies are needed to confirm safety. Thus, informed consent from both the mother and father as to risks/benefits of these drugs is warranted. Case reports of possible withdrawal or toxicity symptoms in newborns exposed in utero to benzodiazepines have included descriptions of increased sedation, abnormal muscle tone, respiratory or sleep problems.27,34,35 For pregnant women struggling with extreme sleep, mood or anxiety symptoms, the benefits of using low dose benzodiazepines may outweigh these reported concerns, however, the lowest effective dose should be prescribed to lower risk of withdrawal and toxicity in infants postpartum.27 In summary, benzodiazepines in pregnancy should not be prescribed carelessly and without a full analysis of the risks/benefits and thorough discussion of these with both parents. AntidepressantsIf the sleep issue in pregnancy is due to depression or anxiety disorder, antidepressants with non-pharmacologic therapy can be helpful. Sedating tricyclic antidepressants maybe a better choice because of lack of evidence of increased risk for major congenital malformations. Though concerns exists regarding the teratogenic effects of antidepressants,36 there is very strong evidence that antidepressants do not raise risk for congenital malformations37-39 with the possible exception of paroxetine which has been associated with cardiac defects in some40 but not other41 studies. Studies have also shown that fetal exposure to maternal depression with or without exposure to an antidepressant also has negative effects on infant health42 Perinatal toxicity effects like jitteriness, respiratory and feeding difficulties, and sedation have been described in cases of exposure to antidepressants but they are generally thought to be short-lived and not life threatening.36,43 Other Pharmacological agentsPregnant women with bipolar disorder presenting with depressive, hypomanic or manic symptoms may require a mood stabilizer along with a sedating atypical antipsychotic or benzodiazepine to regulate sleep. The risks for an evolving bipolar mood episode in pregnancy and postpartum can outweigh the known risks of certain mood stabilizers such as lamotrigine or antipsychotics, particularly older high potency neuroleptics.44 It goes without saying that such cases require a multidisciplinary approach and all such patients must be followed closely by both their Ob/Gyn as well as their psychiatric physicians. CONCLUSIONA majority of women experience sleep disturbances during pregnancy. Changes in sleep architecture result from high circulating hormone levels and physical changes associated with pregnancy. Insomnia is common during pregnancy and should be addressed early in pregnancy. Non pharmacological approaches including CBT-I are effective in treating insomnia, though studies are lacking in pregnant women. Pharmacological approaches should be considered after carefully reviewing risks and benefits of treatment versus no treatment. FootnotesResearch Sponsorship/Funding: None. REFRENCES1. 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Am J Psychiatry. 2004;161(4):608–620. doi:10.1176/appi.ajp.161.4.608. [PubMed] [Google Scholar] Articles from Pakistan Journal of Medical Sciences are provided here courtesy of Professional Medical Publications How should you sleep at 34 weeks pregnant?Sleeping on your left side is often referred to as the “ideal” scenario during pregnancy. Positioning yourself on the left side of your body allows for optimal blood flow from the inferior vena cava (IVC).
How much sleep do I need at 34 weeks pregnant?Between 7 and 9 hours of sleep each day is recommended at the age most women find themselves pregnant.
Why is it so hard to sleep at 34 weeks?But by the third trimester, it can become hard to find a comfortable sleeping position. At this stage, high levels of estrogen can also cause some women to develop rhinitis (swelling of the nasal tissue), which can be associated with snoring and obstructive sleep apnea .
How can I get my third trimester to sleep at night?Although it's impossible for women to avoid many of the things that limit sleep during pregnancy, there are ways to get more (and better) rest:. Develop a relaxing bedtime routine.. Keep a regular bed and wake time.. Avoid electronics for at least an hour before bedtime. ... . Limit caffeine in your diet.. |