Pregnancy and the postpartum period are key times in a woman’s life when sleep disturbances are especially prevalent. In the previous blog, I reviewed the deleterious impact of sleep deprivation on maternal/infant health and the mechanisms causing this association.
This blog will focus on the remedies that can be used in pregnancy.
Initially I will discuss the preferred non-pharmacologic therapies. If further treatment is warranted, we will review medications that are safe to use.
Educating patients on behaviors that promote sleep may require some changes in lifestyle.
- Avoid stimulants such as caffeine and nicotine before bed. Both reduce sleep onset in most people and impair the ability to achieve deep sleep.
- Check with your clinician about other medications that are being taken that may have stimulating effects (asthma medication or thyroid medications) and avoid taking them prior to bedtime, if possible.
- Avoid heavy meals within 2 hours of bedtime. This can interfere with sleep. However, a light snack can be sleep inducing. Some studies have shown that eating food containing carbohydrates before bedtime can improve sleep.
- If heartburn is a cause of insomnia, avoid eating late, avoid spicy food, elevate the head of the bed and use antacids if necessary.
- Avoid drinking excessive fluids in the late evening since pregnant women have to wake up to urinate during the night.(nocturia)
- Regular exercise in the late afternoon or early evening can deepen sleep. However, avoid exercise too close to bedtime which may have a stimulating effect and delay sleep onset.
- The bedroom should be an environment conducive to sleeping–quiet, dark, and comfortable.
- Clinicians may need to recommend an adjustment in bed times and wake times. Later sleep onset time was associated with poorer sleep and reduced total nocturnal sleep time and sleep efficiency. Maintaining regular hours and an earlier bedtime will increase time in bed, assuring a sufficient amount of sleep. At least 8 hours in bed nightly is currently suggested.
- Advise pregnant women to take no more than one nap a day to avoid compromising nighttime sleep quality. Improving nighttime sleep patterns would most likely decrease the need for napping.
- Avoid pregnancy associated discomforts that can cause sleeplessness. Use properly placed pillows and heat to ease back pain. Avoid sleeping with a top leg compressing the bottom leg and wear support hose to prevent leg cramps. When sleep on the side, it may be helpful to place a pillow between the legs.
These are relaxation techniques that release physical and mental tension. Methods may include listening to relaxing music, imagery, meditation, autogenic training, and progressive muscle relaxation.
Sleep specialists have various techniques for breaking the association of going to bed and sleeplessness.
1) Stimulus control therapy
The recommendations are to be in bed only when sleepy and leave the bedroom when awake. This gets repeated as often as necessary throughout the night.
(see addendum for details—reading this protocol may induce sleep!!)
The following is a technique to eliminate sleep related fears for people who try too hard to fall asleep. Some people feel that they “must sleep” or develop significant anxiety or concern that they will be unable to function as a result of not being able to sleep. Educating patients on the fact that one can still perform with reduced sleep and that individuals vary in their sleep requirements can be helpful. Maladaptive thinking patterns associated with sleeping difficulties which increase worry, anxiety, and perpetuate the sleep disturbance are eliminated. Using paradoxical suggestions such as trying to tell the patient to stay awake, rather than sleep can also be helpful in reducing the anxiety.
Pharmacologic therapy may be considered for short term use in cases that don’t respond to therapies such as those already mentioned. The obstetrician and patient must have a full discussion of potential risks and benefits. Treatment decisions should be based on the severity of the insomnia. Medications commonly used for sleep in the nonpregnant state are often category C and D and cannot be used in pregnancy. History reminds us of the potential harmful effects of drugs like thalidomide that doctors in Europe, Australia, Japan, and Canada used in the late 1950s to treat anxiety and insomnia in pregnant women. It was withdrawn from the market in the early 1960s when doctors learned that it caused devastating birth defects when approximately 10,000 children around the world were born with major malformations.
There are 2 hypnotic agents that have been designated class B in pregnancy.(fetal harm unlikely)
Zolpidem (Ambien)-a short acting nonbenzodiazepine hypnotic (Benzodiazepines are associated with an increased risk of malformations when used early in pregnancy and with neonatal flaccidity and respiratory problems when administered late in pregnancy.)
Diphenhydramine (Benadryl)- an antihistamine with a strong sedative effect and a longer duration of action.
There is currently insufficient evidence to support the safety and efficacy of herbal therapies for insomnia in pregnancy.
With growing evidence associating disturbed sleep and detrimental effects on maternal/fetal well being, efforts should be made to maximize restful sleep in pregnancy. Suggestions to enhance the sleep environment along with implementation of sleep behaviors such as regular bedtimes, dietary modifications, positioning aids to support the gravid uterus and extremities can be helpful. In addition, obstetricians may refer patients to therapists who are experienced in the use of relaxation aids along with behavior and cognitive therapies. Medications should be the last resort in the most extreme cases and only after careful discussion with the obstetrician. Research into finding more sleep promoting strategies that are safe and effective in pregnancy is needed.
Addendum, for those still awake!
Sleep Restriction Therapy method:
Calculate average sleep time per night.
Time in bed should be at least 5 hours or the average sleep time–whichever is greater.
Pick a reasonable rise time
Bedtime should be the rise time minus time in bed
Patient should maintain this sleep window for 1 week–going to bed at calculated bedtime and rising at prescribed rise time.(This is called the sleep window).
After 1 week, increase the sleep window based on sleep efficiency
ie. if sleep efficiency is more than 90%–increase bed time by 15 minutes
if sleep efficiency is between 85 and 90%, keep time in bed constant
if sleep efficiency is less than 85% then decrease time in bed by 15 minutes
(sleep efficiency is calculated by time asleep divided by time in bed times 100%)
Keep rise time constant and only adjust bedtime.
Keep making weekly adjustments till optimal sleep efficiency is reached with minimal daytime sleepiness.
Tags: sleep disorders, sleep disutbances, sleep remedies during pregnancy, sleeping while pregnant
