Sleep Matters: Addressing Insomnia in the Perinatal Period · As many as 1 in 3 women start snoring...

Sleep Matters: Addressing

Insomnia in the Perinatal Period

LOUISIANA MENTAL HEALTH PERINATAL PARTNERSHIP

Acknowledgement

This publication was produced by the U.S.

Department of Health and Human Services, Health

Resources and Services Administration, Maternal

and Child Health Bureau under contract number

UK3MC32243. This publication lists non-federal resources in order to provide additional information

to consumers. The views and content in these

resources have not been formally approved by the

U.S. Department of Health and Human Services

(HHS) or the Health Resources and Services Administration (HRSA). Listing these resources is not

an endorsement by HHS or HRSA.

Louisiana Mental Health Perinatal Partnership [email protected] 504-988-9171

Julianna Finelli MDAssistant ProfessorTulane University School of Medicine


The team


Ilana Wahlder

Goals: : Among

health care clinicians who care for

pregnant and

postpartum women:

Increase universal screening for depression, anxiety, substance use disorders (SUDs), and intimate partner v iolence (IPV)

Increase

Increase early detection, evidence-informed first line management, and referral to specialty evidence-based treatments and culturally-appropriate community supports as needed

Increase

Support referral and connections to services, treatment and recovery support in underserved and rural areas of Louisiana.

Support

Develop plan for sustainability of consultation and care coordination beyond the duration of the funding.

Develop


Check in:

Are you enrolled?

We NEED you!

Please enroll at: lamhpp.org (enroll here link)

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Phone consultation


What else?

Webinars

Website (under development)

Telehealth follow-up to phone or in-person

consultation

Onsite consultation in Regions 4 and 8

MOC credit


Aren’t sleep problems in the perinatal period normal?

Sleep problems during pregnancy are common

By the latter part of pregnancy, over 97% report poor sleep (Mindell et al, 2015)

Clinical insomnia rates range between 40-60% (Roman-Galvez et al, 2018)

Sleep problems in the post-partum period are common

Signal et al, 2007 – greatest disruption at one week postpartum

50% of women with insomnia during pregnancy continue to have symptoms at 2 years postpartum (Sivertsen et al, 2015)


Insomnia Disorder

Dissatisfaction with sleep quantity or quality, associated with one or more of the following:

Difficulty initiating sleep

Difficulty maintaining sleep

Early-morning awakening with inability to return to sleep

Clinically significant distress or impairment in functioning

Present for at least 3 months

Occurs at least 3 nights per week

Occurs despite adequate opportunity for sleep


Insomnia is both a disorder and a symptom

Insomnia

Mood Disorders

Anxiety Disorders


Hormonal changes


Why is it important to address sleep?

Preexisting sleep problems can worsen during

pregnancy

Risk for development of sleep apnea, particularly for women who are overweight when they become

pregnant

As many as 1 in 3 women start snoring in pregnancy, and 1

in 10 may develop symptoms of OSA

Up to 30% of women experience symptoms of RLS,

particularly in third trimester


Why is it important to address sleep? Poor sleep may

Increase risk for mood or anxiety disorders

Can exacerbate existing mood or anxiety disorders

Bipolar Disorder

Can negatively impact both partner relationship and parent-infant relationship


Why is it important to address sleep?

Poor sleep may have a negative impact on labor and

delivery

Longer labor, more pain/discomfort during labor, higher rates of preterm labor and C-section (Chang et al, 2010)

Felder et al, 2017 – association between severe sleep disruption

and preterm birth


Screening for sleep problems

Pregnancy

Do you have trouble falling asleep? Staying asleep?

Wake up un-refreshed? Trouble staying awake during

day?

Snoring? Legs restless/uncomfortable before bed?

Post-partum

When you have the opportunity to sleep, are you able to fall asleep?

What are you doing while you’re not sleeping?


Screening for related depression and anxiety disorders


Major

Depressive Disorder

Generalized

Anxiety Disorder

PTSD Manic

episode

Sleep Can be

increased or decreased

Insomnia 2/2

rumination, worry

Sleep

avoidance 2/2 nightmares

Decreased

need for sleep

Associated symptoms

Depressed

mood, anhedonia, guilt, suicidal

ideation

Excessive worry

that is difficult to control; restlessness,

irritability, muscle tension

Intrusive

images, flashbacks, distress with

exposure to triggers,

hypervigilance

Elevated or

irritable mood, more talkative,

racing thoughts,

increased activ ity, impulsiv ity

Recommendations for universal maternal depression screen

ACOG (2018)

Screen at least once during the perinatal period for depression

and anxiety symptoms

Assess mood and emotional (including repeat screening) at the first comprehensive postpartum visit

Be prepared to initiate medical therapy, refer to behavioral health

resources, or both when indicated

American Academy of Pediatrics (2016)

Screen for maternal depression at 1, 2, 4,and 6-month visits


Edinburgh Postnatal Depression Scale (EPDS)

Validated screen for

depression and anxiety in

pregnancy and postpartum

period

FREE (LAMHPP.org)

< 5 minutes to complete

Available in 50 languages

Easy to score


First-line sleep interventions

Treating mood and anxiety disorders when present

Treating pregnancy-related symptoms

GERD

Nausea

RLS (checking folate/iron level and treating as

appropriate)

Sleep hygiene


What is sleep hygiene?

Practices and habits that are necessary for good

nighttime sleep quality and full daytime alertness

(National Sleep Foundation)

Many practices are based on behavioral principles

CBT-I


Addressing sleep


Physiology

Stimulus Control

Rhythms

Sleep hygiene measures: Physiology

Manage GERD

Eat frequent, small meals during the day

Avoid large amounts of spicy/acidic/fried foods

Raise head of bed/sleep on more pillows if symptoms of GERD

Sleep position

Lie on your left side with knees and hips bent; place pillows between your knees, under your abdomen, and behind your back

Cut down on fluids 2-3 hours before bedtime

Exercise for at least 30 min per day (unless contraindicated)


Sleep hygiene measures: Rhythm

Routine/consistency is critical

Go to bed and wake up at the same time every day

Includes weekends!

Turn off all screens (TV, tablet, phone) at least 30 min

before bedtime

Bathroom nightlight can prevent need for turning on

bright lights (less arousing)

Sleep rituals

Warm bath, caffeine-free tea, 15 min of stretches/breathing


Sleep hygiene measures: Stimulus Control

Bed should be used for sleep and sex only

Avoid working, watching TV in bed

If you are still awake after 30 minutes in bed, get out of bed*

Try a quiet, low-light activity until you begin to feel sleepy again

Daytime naps if necessary, but should be minimized

or moved earlier in day if difficulty sleeping at night

*unless contraindicated


Postpartum sleep

Breastfeeding considerations

Environmental (crib in vs. out of bedroom)

Partner/co-parent helping with nighttime feeds

Particularly for mothers with bipolar disorder, risk/benefit may favor bottle feeding

Soothing techniques

Pacifiers (after breastfeeding is well-established), swaddling, rocking, routine, white noise, etc.

Social supports

Reassurance/normalization


Second line interventions -medications

Effects of sleep medications on the fetus have not

been well studied

Difficult to control for potential confounding

variables

Concomitant exposures

Confounding by indication

Effects of underlying illness

Take-home point: Risk/benefit


Second-line interventions: Medications

Antihistamines

Hydroxyzine, doxylamine, diphenhydramine

Several meta-analyses did not demonstrate association

with congenital malformations

Breastfeeding – limited data; only minimal amounts

shown to be secreted in breast milk; reports of irritabil ity

and colicky symptoms in 10% of infants, drowsiness in 1.6% of infants, none requiring medical attention

(Motherisk study)


Second-line interventions: Medications

Benzodiazepines

Anxiolytic properties

Sum of the available data do not support teratogenicity of benzodiazepines

Some studies have found associations between benzodiazepine use and preterm delivery, low birth rate

If taken near the time of delivery, newborn may experience toxicity or withdrawal symptoms

Recommend avoiding use with diphenhydramine

Breastfeeding: favor short-acting (lorazepam)


Coming soon: LAMHPP local resource guides


Plan: Referral Info

Louisiana Mental Health Perinatal Partnership

[email protected] 504-988-9171

Plan: Postpartum Support International

Clinician-

moderated

online support

group

Online

information

Link to peer

supports


Louisiana Mental Health Perinatal

Partnership [email protected] 504-988-9171

References

I to S, Blajchman A, Stephenson M, Eliopoulos C, Koren G. Prospective follow-up of adverse reactions in breast-fed infants exposed to maternal medication. Am J Obstet Gynecol. 1993;168(5):1393–9.

Mindell JA, Cook RA, Nikolovski J. Sleep patterns and sleep disturbances across pregnancy. Sleep Med 2015; 16: 483–488.

Roman-Galvez RM, Amezcua-Prieto C, Salcedo-Bellido I, Mart ínez-Galiano

JM, Khan KS, Bueno-Cavanillas A. Factors associated with insomnia in pregnancy: a prospective Cohort Study. Eur J Obstet Gynecol Reprod Biol 2018;221:70–5.

Sivertsen B, Hysing M, Dorheim SK, Eberhard-Gran M. Trajectories of maternal

sleep problems before and after childbirth: a longitudinal populat ion-based study. BMC Pregnancy Childbirth 2015;15:129.

T. L. Signal, P. H. Gander, M. R. Sangalli, N. Travier, R. T. Firestone, and J. F. Tuohy, “Sleep

duration and quality in healthy nulliparous and multiparous women across pregnancy and

post-partum,” Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 47,

no. 1, pp. 16–22, 2007.


Sleep Matters: Addressing Insomnia in the Perinatal Period · As many as 1 in 3 women start snoring...

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Transcript of Sleep Matters: Addressing Insomnia in the Perinatal Period · As many as 1 in 3 women start snoring...