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Steven Y Park, MD  
Male, 47
New York, NY

Specialties: Sleep-breathing disorders

Interests: Running, Baking, origami
Private Practice
212-315-9058
New York, NY
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What All Pregnant Women Must Know

Jan 16, 2009 - 14 comments
Tags:

progesterone

,

Sleep Apnea

,

CPAP

,

Pregnancy

,

post-partum

,

Depression

,

pre-eclampsia



My wife Kathy is expecting our third son any day now, and her experiences during her current and past pregnancies bring up some important issues that all men and women, pregnant or not, should know about. Even though poor sleep, nasal congestion, post-partum depression, and weight gain are almost an accepted part of pregnancy, these can be especially problematic for those women who struggle to bounce back way beyond their first year after pregnancy. Besides the excess weight that they can’t seem to take off, many of these women find that their health and energy level are considerably worse off than it was prior to being pregnant.

However, there are measures you can take prior to delivery to help you get back to the way you felt before you became pregnant. There are some important concepts related to pregnancy, that are often overlooked by many medical professionals but  if looked at from my sleep-breathing paradigm, explains why these events occur, and what you can do about it.

What You Don’t Know Can Harm You

In my book, Sleep, Interrupted I allude to a eureka moment when my wife helped me to realize what helped her to rid herself of her post-partum depression after our first two sons were born.

It’s a given that you’ll gain weight if you’re pregnant. What many of us don’t think about however is that when you gain weight in your abdominal area, the fat cells inside your tongue and throat area get enlarged as well. This fact alone can have significant consequences for pregnant women, during, and especially after pregnancy.

As I explain exhaustively in my book, Sleep Interrupted, all modern humans are susceptible to upper airway narrowing and collapse due to various degrees. And because the airway is a uniquely dynamic apparatus that’s modified by any change in the soft tissues surrounding the area, weight gain can dramatically impact the rate of inspiration and expiration especially while we sleep, when the muscles and soft tissues lose tension and lose slack.

As I’ll explain further, this is one reason why, even those who are not pregnant, can progress into the extreme end of this sleep breathing problem called obstructive sleep apnea. Similarly, any amount of weight gain can move you up on this line to some degree. This is why many pregnant women begin to snore, especially in their third trimesters.

Complications During Pregnancy

Pre-eclamspia and gestational diabetes are two common conditions during mid to late pregnancy. These conditions are thought to be distinct clinical conditions specific to pregnant women. Pre-eclampsia is a potentially dangerous condition where the mother to be develops severe high blood pressure with a risk of kidney failure, and death for the baby.

Gestational diabetes is another dangerous condition for both the mother and the baby. There are many studies that have reported an association between obstructive sleep apnea and these two conditions during pregnancy, but they are typically seen as occasional, isolated events. Doctors usually recommend dietary and lifestyle changes and then resort to medications when conservative options don’t work.

But despite numerous studies showing that women with pre-eclampsia can be effectively treated with CPAP (continuous positive airway pressure), it’s thought of as a rare oddity and has not gained attention as a very common way of treating pre-eclampsia. The same situation applies to gestational diabetes.

The Importance of Sleep Position In Pregnancy

Women are recommended to sleep on their left side during pregnancy, presumably due to less pressure on internal vital organs and blood vessels by the growing fetus. This is especially true in the third trimester. But one thing to consider is that as women gain weight, if they go on to develop mild or significant sleep-breathing problems, by necessity, they naturally will prefer to sleep on their sides anyway.

Similarly, many people with sleep-breathing problems already sleep on their sides or stomachs already for the following reasons: Due to various degrees of jaw narrowing, the tongue and voice box (which grow to their normal size), takes up too much space inside the mouth. These are the people who gag easily when a doctor presses the tongue depressor forcefully so that the back of the throat can be seen behind the tongue. For these people when they lie down flat on their backs, the tongue falls back partially due to gravity making the airway that much narrower. In this position, the person usually breathes through a slit only 2-3 mm wide. While awake, breathing is normal since your throat muscle tone increases as you inspire.

However, once you fall off to sleep, and especially as you enter deeper levels of sleep, by definition, all your muscles, including your throat and tongue muscles, must relax. With only 2-3 mms of opening, and with tongue muscle relaxation, your tongue will fall back, causing obstruction. Most people will wake up consciously or subconsciously after a second or two, and then turn over to the side. However, if you stopped breathing for 10 seconds or longer, then you just had an apnea. Most people compensate partially by sleeping on their sides or stomachs, but this is usually not good enough.

This is why when pregnant women gain weight, the fat cells in their throat will narrow the throat, and aggravate this vicious cycle. During this process, if you happen to also catch a simple cold or suffer and allergy attack, the mild inflammation that occurs in the breathing passageways can further narrow the throat, aggravating more tongue collapse. Once you obstruct, tremendous vacuum pressures in your throat causes mild amounts of normal stomach juices to come up into your throat, causing more inflammation and narrowing in the throat.

It’s also been shown that these same juices can go up into the nose, aggravating nasal congestion. Nasal congestion aggravates further tongue collapse by causing a vacuum effect downstream. This is why given these circumstances, gaining weight during pregnancy, albeit normal, should be gradual and moderated.

Progesterone’s Secret

Although pregnancy and in particular the weight gain that it induces many unfavorable side effects for women, there’s one unique advantage that pregnant women have during pregnancy that many men with sleep breathing problems don’t have called progesterone.

Progesterone is a hormone that vitally involved with a woman’s reproductive cycle (along with estrogen). During a woman’s monthly cycle, estrogen helps to stimulate egg development and release, whereas progesterone promotes uterine health, to support any possible embryo development. One little known feature about progesterone that even many doctors aren’t aware of is the fact that it acts as an upper airway muscle dilator. This can have profound effects on your tongue, giving it more muscle tone.

For pregnant women, this slight muscle tone is, in effect, what helps them to counteract what could be a detrimental side affect to their weight gain during pregnancy. However, during post-pregnancy when these levels taper off, is another story. Studies have shown that tongue muscle tone is lower in post-menopausal women and increased significantly when progesterone is added.

Imagine the effects of diminishing progesterone just before womens’ periods, or during menopause, when progesterone begins to slowly drop beginning in the early 40s. The same thing occurs during pregnancy: progesterone shoots up during pregnancy and drops immediately after delivery. During pregnancy, despite all the expected weight gain, progesterone (besides maintaining uterine health) prevents the tongue from falling back. But once a woman delivers and progesterone drops, you’re left with all the added weight of pregnancy without the added protection of progesterone. No wonder women have trouble sleeping the first few weeks after delivery (besides having to feed the baby every few hours).

In retrospect, these factors severely affected the way my wife felt right after my first son was born. It took her almost a year before her post-partum depression resolved completely after our first son was born. Only after she lost all her pregnancy weight did she begin to feel better.

Breathe Better, Sleep Better, Feel Better

Although pregnancy can impact the way you breathe, and thereby affect the way you sleep during and even after you deliver, there are simple ways to minimize the negative side effects and expedite your post-partum recovery process.
The first thing you must do is to keep all your airway passages clear and congestion free and this includes your nose. If your nose is stuffy, the simplest thing to do is to apply nasal saline, which come in various nasal applicators from sprays to pumps to Water-Pik machines. Another popular way of getting salt water into your nose is a Neti-pot, which is an Indian Alladin’s lamp-like container where you mix your saline and pour it into your nose.

If your nostrils collapse when you breath in, then nasal dilator strips (Breathe-rite is one brand), or internal nasal dilator devices (Nozovent, Breathewitheez, Nasalcones are three examples) may help. Sometimes women are placed on allergy medications for pollens, dust or pets. This should be done under a care of your medical doctor. If none of these options work, it’s time to see an ear, nose and throat doctor.

If you normally like to sleep on your stomach or side, then your tongue may be susceptible to collapse. There are various dental devices that are available for snoring and mild to moderate obstructive sleep apnea. Although not officially designed for use in pregnant women, these devices are not harmful for the baby and can only help the baby since it helps the mother sleep better.

If you have any of the complications of pregnancy or if your fatigue is to severe to the point where you are incapacitated, a consultation with a sleep doctor may be warranted. CPAP, or continuous positive airway pressure, has been studied and found to be useful in a handful of small, preliminary studies.

The most important thing to do after delivery is to try to lose the pregnancy weight. This is obviously easier said than done, but there is a direct correlation between your persistent weight and how you will feel. You may want to consider working with a healthcare professional (your medical doctor, dietician or trainer). The devices mentioned during pregnancy may be appropriate for afterwards the delivery as well.

Whether or not you’re pregnant, breathing well while you’re sleeping is vital to your overall state of health. But if you’re pregnant, it’s even more important that you breathe well, especially in the immediate period just after you deliver.


Steven Y. Park, M.D.
http://www.doctorstevenpark.com


Comments
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by stella5349, Jan 16, 2009
Let us know when she has the baby.

We are all waiting to hear.

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by flutter7, Jan 16, 2009
If someone becomes pregnant and has sleep apnea (besides the progesterone benefits), which is not properly treated, what affect does this have on the fetus. All those apneas/hypopneas surely cannot be good for a growing fetus?



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by KD9ER, Jan 18, 2009
Could this be why two years later I'm still having sleep issues?  I do not believe I produce the right amount of either progesterone or estrogen.  Once I start taking birth control it's like my body is on clomid, everything starts functioning a little too well.  My sleep issues became extreme after my son was born.  It makes sense when you explained it like that, it really does.

I'm buying your book.  I need to do some reading and help my doctors help me.  I see an Internal Meds doc, but not everyone is aware of other specialties that relate so well to their field of study.  I understand because on top of patient loads, home life, etc most people do not have the time to sit down and do more research.  Thus, I need to be that advocate, that research link to help or bring up some alternate views on what might be causing certain problems with my body.  So far all we have are pieces to a puzzle, but we're missing some important parts that make the picture whole.  You really hit the nail on the head when you mentioned in one of your posts that western doctors do not look at the medical problems as interrelated, instead treat them individually.  I honestly believe if I had a doctor who would look at me and agree that I do not have 10 different disorders, but mainly one or possibly two then I'd be a lot healthier right now.

Thank you for all of your posts.  I do love reading them as they really are very helpful.  Keep posting.  You really are making a difference in this world.  More doctors need to be like you.

Thank you Dr. Parks!
-KD9ER

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by Steven Y Park, MDBlank, Jan 18, 2009
flutter7,

Having sleep apnea during pregnancy definitely has detrimental effects on the baby. There are many studies that prove this. One study showed that women who snored more during pregnancy had babies that had relatively lower Apgar scores at birth.

http://www.doctorstevenpark.com

Avatar_dr_m_tn
by Steven Y Park, MDBlank, Jan 18, 2009
KD9ER,

Thanks for your comments. I'm confident that you'll benefit from reading the book. As you can probably tell, since my wife is going through this again, it's something that I pursue with a passion on a personal level.

http://www.doctorstevenpark.com

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by Aprizzle, Jan 19, 2009
So is it beneficial to use a progesterone cream after delivery? What would be the benefits?

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by sarah3333, Jan 21, 2009
I didn't know if were that close, I will came see you for my next baby.
Doctor Seecomar Lesly is my doctor next door.# 600

Thanks

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by Esbie, Jan 23, 2009
Does stuffy nose have effect on the baby? I`ve been having this 2 weeks now? I bought  a NASAL Moisturizing Spray but my doctor said it`s not recommended for pregnant women. I tried Sudafed but it didn`t work too. Is there any possible way on how i stop???

Thanks so much!

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by giz869, Jan 26, 2009
i haven't seen my period in 2 months buts now and again i have spotted some redish pinkish blood could i be pregnant if not what is it?

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by starfish1963, Jan 30, 2009
Great information.  I will certainly pass this along to the young ladies I have in my life having babies and also, my father who is a type two diabetic and does have sleeping issues but is unable to loose the weight due to years of over eating and insuline use.
thank you kindly for this information, I know without a doubt it will help a lot of women and I pray it gets out there to as many that would need it.  Information is Power!  if applied :)


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by tara1209, Jan 30, 2009
I am a nurse and I have homecare . I have a patient who have 45 years old . she married for 3 months ago . she had quit 7 days before with condom but she take semen of her husband in the condom and pur its into her vaginal . do you think she might be pregnant or no ? thanks

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by Steven Y Park, MDBlank, Jan 30, 2009
Esbie,

If you're talking about non-medicated nasal saline, it's perfectly safe to use. Your doctor probably thinks you're talking about medicated decongestant or topical steroid sprays.

Having a stuffy nose can create problems with your general health, as well a aggravating poor breathing at night which leads to poor quality sleep, which ultimately is not healthy for your baby.

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by robina648, Jan 31, 2009
I took Celexa while I was throughout my pregnancy with my daughter.  She has congenital hypothyroidism.  I read that hypothyroidism was a rare side effect of Celexa (posted on this website), so I wonder if there are any connection to hypothyroidism.  If not, do you know of any studies that are looking at causes of congenital hypothyroidism?

Avatar_dr_m_tn
by Steven Y Park, MDBlank, Jan 31, 2009
It's thought that congenital hypothyroidism is due to a number of reasons, including underdevelopment of the the thyroid gland, abnormal pituitary TSH, and inborn error of thyroid metabolism, or an iodine deficiency. Maternal thyroid problems can also affect the fetus significantly. I'm not aware of any studies linking Celexa and congenital hypothyroidism, but they must have seen some episodes during the clinical studies. Unfortunately, you can't prove that one caused the other. One other thing to consider is that increased stress hormones during pregnancy (from whatever reason) can suppress thyroid function.

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