Sleep Disordered Breathing and Gestational Hypertension: Postpartum Follow-up Study

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1 SDB AND GESTATIONAL HYPERTENSION: POSTPARTUM FOLLOW-UP Sleep Disordered Brething nd Gesttionl Hypertension: Postprtum Follow-up Study John Reid, MD 1 ; Riley A. Glew, MPH 1 ; Robert Skomro, MD 1 ; Mrk Fenton, MD 1 ; Dvid Cotton, MD 1 ; Femi Oltunbosun, MD 1 ; John Gjevre, MD 1 ; Christin Guilleminult, MD 2 1 University of Ssktchewn, Ssktoon, SK Cnd; 2 Stnford University, Plo Alto, CA Bckground: Gesttionl hypertension (GH) is newly recognized risk fctor for dverse crdiovsculr events lter in life. Sleep disordered brething (SDB) is n estblished risk fctor for dverse crdiovsculr events. Recent reserch hs suggested tht women with GH my hve n incresed rte of SDB during pregnncy, but it is not known if this higher rte of SDB persists into the postprtum stte. Objective: To ssess whether women with GH continue to hve n incresed rte of SDB compred to helthy pregnnt women, fter the physiologic chnges of pregnncy resolve. Methods: We previously studied women with GH nd uncomplicted pregnncies with sleep questionnires nd level 1 polysomnogrphy. Prticipnts were invited to prticipte in repet testing 1-2 yers postprtum. Respirtory disturbnce index (RDI) differences were ssessed. Results: Eighteen subjects (11 GH nd 7 helthy) hd complete follow-up dt vilble for comprison with nteprtum dt. This group ws representtive of the initil nteprtum cohort. Women with GH experienced decrese in men RDI from nteprtum to postprtum (12.0 ± 12.3 vs 2.9 ± 2.9; P = 0.02). Helthy women did not experience the sme chnge (2.8 ± 5.3 vs 2.1 ± 3.2; P = 0.81). Postprtum comprisons showed the men RDI of women with GH hd decresed to be similr to tht of helthy women (P = 0.75). Conclusions: SDB in women with gesttionl hypertension improved in the postprtum stte to levels indistinguishble from our helthy subjects. This suggests tht the physiologic effects of pregnncy my hve hd pthologic role in the development of nteprtum SDB in women with GH. Keywords: Gesttionl hypertension, postprtum, preeclmpsi, sleep disordered brething Cittion: Reid J; Glew RA; Skomro R; Fenton M; Cotton D; Oltunbosun F; Gjevre J; Guilleminult C. Sleep disordered brething nd gesttionl hypertension: postprtum follow-up study. SLEEP 2013;36(5): INTRODUCTION Gesttionl hypertension (GH) is newly recognized risk fctor for mternl crdiovsculr events lter in life. 1 Sleep disordered brething (SDB) is n estblished risk fctor for dverse crdiovsculr events. 2 Compred to women with uncomplicted pregnncies, women with GH complin of lower qulity sleep nd hve incresed rtes of nsl congestion, snoring, nd SDB. 3-5 Pregnncy is known to excerbte preexisting SDB, 6 but it is not known if the incresed rte of SDB in women with GH decreses to bseline fter the physiologic chnges of pregnncy hve resolved. If not, unrecognized nd untreted SDB my contribute to the incresed crdiovsculr risk tht is found in women with history of GH. 7 We hd previously reported higher respirtory disturbnce index (RDI) nd frequency of SDB (defined s RDI 5) in women with GH compred to women with uncomplicted pregnncies. 4 In this current study we report dt from follow-up evlutions of these subjects, performed between one nd two yers postprtum. The study hd two phses: phse one ws questionnire-bsed, in which we miled out questionnires of sleep qulity nd dytime tiredness to prticipnts in the originl study. Along with the questionnires, we miled n invittion to return to the sleep lbortory for full overnight PSG. Results from the questionnires nd PSG were compred to those from Submitted for publiction April, 2012 Submitted in finl revised form November, 2012 Accepted for publiction December, 2012 Address correspondence to: John Reid, MD, Division of Respirtory Medicine, 5 th Floor Ellis Hll, 103 Hospitl Drive, Ssktoon, SK Cnd S7N 0W8; Tel: (306) ; Fx: (306) ; E-mil: j.reid@ussk.c the originl nteprtum study. Our hypothesis ws tht women with GH would continue to hve higher RDI nd higher rte of SDB thn women with uncomplicted pregnncies. METHODS Written informed consent ws obtined for ll ptients included in the study protocol, which ws pproved by the University of Ssktchewn Biomedicl Ethics Review Bord nd registered with the Ntionl Institute of Helth Clinicl Trils Registry (Identifier NCT ). Prticiption ws voluntry. For returning mil-in questionnires, women s nmes were entered into drw for one of three ipod Shuffles. An honorrium of $100 ws provided for those who greed to return for repet PSG. Prticipnts Follow-up questionnires were miled to ll 60 prticipnts in our originl study, between 1-2 yers postprtum, with self-ddressed, pre-stmped return envelopes. In ddition to questionnires, women were invited to return to the sleep lb for repet PSG for comprison to their nteprtum study. Of the originl 60 prticipnts, we were unble to locte 3; 14 never returned questionnires despite repeted requests; nd 8 were excluded becuse of current pregnncy. The remining 35 non-pregnnt women completed questionnires, nd 19 greed to return for repet PSG. One of these 19 did not hve dequte nteprtum PSG dt, leving 18 women (11 GH nd 7 helthy) for full nteprtum to postprtum comprison. This group of 18 women ws resonbly representtive of the cohort in the originl nteprtum study (Supplementl Tbles S1, S2), the only differences being tht helthy women who cme in for postprtum ssessment hd higher ESS (P = 0.01) nd snoring prevlence SLEEP, Vol. 36, No. 5, Follow Up of SDB in Gestionl Hypertension Reid et l

2 (P = 0.03) t their nteprtum ssessment thn women without follow-up. One womn in the GH group ws still receiving tretment for hypertension. This ptient hd pre-existing hypertension prior to pregnncy, nd her dignosis of GH ws bsed on pregnncy-relted deteriortion in hypertensive control. None of the other subjects in either group ws being treted for hypertension t the time of follow-up study. All follow-up ssessments were completed months postprtum, nd ll women hd completed lctting by the time of their follow-up evlution Procedures Bseline dt were collected for ge, height, weight, body mss index (BMI), nd snoring history. Extensive nthropometric dt (e.g., neck, chest, nd bdominl circumferences s well s Mllmpti score, tonsillr size, nd mxillry overjet) hd been collected for the nteprtum study, but none were found to be predictive of SDB in our cohort. We therefore did not collect this dt for the follow-up study. Subjects completed series of short questionnires, which ddressed both sleepiness nd common signs or symptoms of SDB. These included the Epworth Sleepiness Score (ESS), the Pittsburgh Sleep Qulity Index (PSQI), the Berlin Questionnire, nd visul nlogue scle (VAS) of sleep qulity which sked subjects to rte their current sleep on horizontl scle between worst nd best. This ws converted to percentge score, with worst being 0% nd best being 100%. For those subjects who consented, the questionnire ssessment ws followed by full-night dignostic PSG (Sndmn 8.0, Tyco Inc., Ottw, Cnd) performed in the Royl University Hospitl Sleep Lbortory. PSG chnnels included electroencephlogrm, electrooculogrm, submentl electromyogrm, pulse oximetry, nsl irflow pressure sensor nd oronsl thermistor irflow, chest nd bdominl excursion by piezoelectric belt, snore vibrtion sensor, intercostl surfce EMG, nd nterior tibilis EMG, nd electrocrdiogrm. Studies were scored ccording the Americn Acdemy of Sleep Medicine recommended criteri 8 by single registered sleep technicin who ws blinded to clinicl dt. Accordingly, events were ctegorized s pnes ( decrese in irflow 90% from bseline for 10 sec); hypopnes (decrese in irflow 30% for 10 sec nd followed by desturtion of 4% from the pre-event bseline); nd respirtory event-relted rousls (RERAs), defined s sequence of breths lsting 10 sec, ssocited with flttening of the nsl pressure wveform leding to n rousl from sleep, nd the sequence does not meet criteri for n pne or hypopne. The RDI represented the totl number of pnes, hypopnes, nd RERAs divided by the hours of sleep. Dt Anlysis Comprisons were conducted between nteprtum nd postprtum mesurements; these comprisons were conducted seprtely for helthy women nd women with GH. Normlity ws ssessed with the Shpiro-Wilk test 9 nd QQ plots. Mens were compred for normlly distributed vribles using repeted mesures t-test, while the distributions of vribles tht were not normlly distributed were compred with the Wilcoxon signed-rnk test. Ctegoricl vribles consisting of count dt were ssessed using the χ 2 test. The nlyses presented in the supplementl tbles used t-tests, Mnn-Whitney U tests, nd χ 2 tests for norml, non-norml, nd ctegoricl dt, respectively. A generlized liner model ws used to estimte n djusted men RDI. Since RDI (dependent vrible) ws not normlly distributed, nd the dt used to derive RDI is bsed on counts, Poisson or negtive binomil distributions re pproprite for modeling the dt. The Poisson distribution mkes the restrictive ssumption tht the men nd vrince of RDI re equl, 10 while the negtive binomil distribution relxes this ssumption. 11 Men RDI ws 5.5 nd vrince ws 71.3, indicting tht negtive binomil distribution ws n pproprite choice of distributions. An dvntge of the regression model is tht men RDI cn be determined while differences in sleep time re explicitly modeled by using TST s the model offset. The regression model is expressed s: ln RDI TST = β 0 + β 1 X nteprtum Generlized estimting equtions were used to ccount for repeted mesures, using working correltion mtrix to estimte robust stndrd errors. 12 Model residuls were used to ssess fit which confirmed distribution ssumptions nd vrince homogeneity. Dt ws recorded nd stored with Microsoft Excel, nd ll nlysis ws conducted with SAS softwre version 9.2 (SAS Institute Inc., Cry, NC, USA). Sttisticl significnce ws ssessed using α = RESULTS Women with GH experienced chnges in their sleep chrcteristics between their nteprtum nd postprtum PSG ssessments (Tble 1). Notbly, the nteprtum BMI decresed from 37.6 ± 5.9 kg/m 2 to 32.5 ± 6.8 kg/m 2 (P < 0.01). Sleep efficiency (60.4 ± 16.6 vs ± 16.6 min; P = 0.02), % REM (7.4 ± 5.1 vs ± 6.4; P < 0.01), sleep qulity (36.2 ± 14.9 vs ± 23.3; P = 0.01), nd TST (235.2 ± 66.7 vs ± min; P = 0.01) ll incresed, while the rousl index decresed (19.5 ± 14.8 vs. 6.0 ± 4.0; P < 0.01). Most importntly, the RDI decresed significntly from nteprtum to postprtum (12.0 ± 12.3 vs 2.9 ± 2.9; P = 0.02). Not surprisingly, the helthy women lso experienced decrese in BMI (28.8 ± 4.2 kg/m 2 to 22.8 ± 4.0 kg/m 2 ; P < 0.01), but otherwise experienced fewer chnges in their sleep chrcteristics thn the women with GH (Tble 2). Specificlly, the chnge in TST for helthy women ws not sttisticlly significnt ( to ; P = 0.08), nd the RDI decresed non-significntly from 2.8 ± 5.3 to 2.1 ± 3.2 (P = 0.81). Helthy women did spend significntly higher percentge of sleep in the supine position (22.3 ± 22.6 vs ± 31.6; P = 0.03) compred to nteprtum. The postprtum results for women with GH nd helthy women were then compred ginst ech other. Interestingly, despite the women with GH still hving much higher men BMI (32.5 ± 6.8 vs ± 4.0; P < 0.01), there ws no difference in self-reported snoring (45% vs 57%; P = 0.63) or mesured RDI (2.9 ± 2.9 vs 2.1 ± 3.2; P = 0.75; Tble S3). Anteprtum comprisons of women with GH versus helthy women re provided for the interested reder in Tble S4. Hving shown tht women with GH experience postprtum decrese in RDI reltive to nteprtum, while helthy women do not, we sought to obtin n djusted estimte of RDI. The SLEEP, Vol. 36, No. 5, Follow Up of SDB in Gestionl Hypertension Reid et l

3 djusted RDI ws determined for women with GH nd helthy women seprtely, with negtive binomil regression model. Women with GH demonstrted decrese in djusted RDI from 12.7 (95% CI: ) t nteprtum to 3.9 (95% CI: ) postprtum (Figure 1). In contrst, helthy women hd n djusted nteprtum RDI of 3.0 (95% CI: ) which decresed to 2.3 ( ) postprtum (Figure 1). DISCUSSION We previously found tht women with GH hve higher RDI nd incresed rte of SDB compred to helthy pregnnt women, 4 but incresed obesity in the GH group ws significnt confounding fctor. We hd postulted for this study tht we would find high degree of SDB persisting in postprtum for the women with GH, which we did not find. Insted, we found tht despite the women with GH remining substntilly more obese thn the helthy group, their men RDI decresed to be indistinguishble from the helthy postprtum women. Along the sme lines, self-reported snoring ws not incresed in the postprtum stte for women with GH. While the smll number of subjects is limittion, our findings mke us consider tht pregnncy-relted fctors, rther thn just obesity, my hve cusl role in the elevted nteprtum RDI observed in GH subjects. It my be tht the physiologic chnges of pregnncy unmsked tendency towrds SDB, which then remitted once pregnncy ws over. We speculte tht perhps this propensity towrds SDB could be gin unmsked lter in life with ge-relted physiologic chnges, menopuse nd/or weight gin. Obesity is n estblished risk fctor for SDB nd this remined chrcteristic of the GH group into the postprtum period. However, there re mny other nthropometric nd physiologic (e.g., fluid retention) fetures tht cn hve contributory role in SDB nd mny of these my be modifible by pregnncy. While we filed to find predictive vlue for ny of these fetures during our nteprtum study, this my hve been consequence of our smll smple size nd we believe tht these fetures should be evluted in future, lrger studies in this re. The short-term follow up nture of this study hs both dvntges nd disdvntges. The dvntge is tht it llows for resonble ssessment of the effect of pregnncy physiology on sleep nd brething. However, we cnnot sy whether or not the improvement in SDB we observed in the first two yers postprtum will be mintined s our subjects ge. Therefore, our study does not ssess whether the occurrence of SDB is contemporneous with known elevted crdiovsculr event rte in older women who hve history of GH. 7 Obvious limittions to our study include the smll size s well s Tble 1 Gesttionl hypertension nteprtum vs. postprtum Anteprtum (n = 11) Postprtum (n = 11) Age (yer) 27.9 ± 4.7 (27.0) 29.7 ± 4.5 (28.0) Follow-up time (months) 17.1 ± 4.4 (16.0) BMI (kg/m 2 ) 37.6 ± 5.9 (36.2) 32.5 ± 6.8 (32.3) < 0.01 ESS 6.3 ± 3.2 (5.0) 6.3 ± 3.1 (5.0) 1.00 Sleep qulity VAS (%) 36.2 ± 14.9 (30.5) 49.0 ± 23.3 (41.9) 0.01 b Snoring (yes/no) 9 (82%) 5 (45%) 0.07 c TST (min) ± 66.7 (242.0) ± (408.0) 0.01 Sleep efficiency (%) 60.4 ± 16.6 (61.6) 83.1 ± 16.6 (88.3) 0.02 b % Supine (%) 22.2 ± 26.0 (9.9) 36.5 ± 30.0 (35.9) 0.32 b % REM (%) 7.4 ± 5.1 (7.3) 13.9 ± 6.4 (13.1) < 0.01 AHI (events/h) 4.6 ± 9.3 (0.3) 2.6 ± 2.7 (1.3) 0.77 b RDI (events/h) 12.0 ± 12.3 (6.4) 2.9 ± 2.9 (1.9) 0.02 b Arousl index (events/h) 19.5 ± 14.8 (15.6) 6.0 ± 4.0 (6.1) < 0.01 b Men SpO 2 (%) 95.7 ± 1.3 (96.0) 96.6 ± 1.5 (96.7) 0.06 Min SpO 2 (%) 90.7 ± 4.0 (93.0) 91.1 ± 5.2 (93.0) 0.63 b Pired t-test comprison of mens. b Wilcoxon signed-rnk comprison of distribution. c Chisqure test comprison of counts. BMI, body mss index; ESS, Epworth Sleepiness Scle; AHI, pne hypopne index; RDI, respirtory disturbnce index; TST, totl sleep time. Tble 2 Helthy subjects nteprtum vs. postprtum Anteprtum (n = 7) Postprtum (n = 7) Age (yer) 29.9 ± 6.9 (32.0) 31.9 ± 6.9 (33.0) Follow-up time (months) 17.6 ± 2.8 (18.0) BMI (kg/m 2 ) 28.8 ± 4.2 (27.2) 22.8 ± 4.0 (21.7) < 0.01 ESS 11.0 ± 4.0 (10.0) 11.4 ± 4.1 (11.0) 0.08 Snoring (yes/no) 5 (71%) 4 (57%) 0.57 c Sleep Qulity VAS (%) 52.1 ± 18.7 (53.2) 51.8 ± 25.0 (66.2) 0.81 b TST (min) ± 49.3 (309.0) ± 42.0 (391.8) 0.08 Sleep Efficiency (%) 80.7 ± 9.2 (81.1) 88.2 ± 3.4 (88.4) 0.11 b % Supine (%) 22.3 ± 22.6 (10.7) 45.5 ± 31.6 (31.0) 0.03 b % REM (%) 15.2 ± 2.4 (15.5) 13.8 ± 3.8 (13.8) 0.50 AHI (events/h) 0.9 ± 2.4 (0.0) 1.1 ± 2.0 (0.3) 0.31 b RDI (events/h) 2.8 ± 5.3 (1.2) 2.1 ± 3.2 (1.2) 0.81 b Arousl index (events/h) 10.3 ± 6.9 (7.4) 5.6 ± 4.7 (4.8) 0.11 b Men SpO 2 (%) 96.7 ± 1.3 (96.8) 97.0 ± 0.8 (97.3) 0.41 Min SpO 2 (%) 93.0 ± 2.8 (94.0) 93.0 ± 3.7 (95.0) 1.00 b Pired t-test comprison of mens. b Wilcoxon signed-rnk comprison of distribution. c Chisqure test comprison of counts; BMI, body mss index; ESS, Epworth Sleepiness Scle; AHI, pne hypopne index; RDI, respirtory disturbnce index; TST, totl sleep time. the fct tht we studied only one-third of our initil nteprtum cohort. However, this low follow-up rte is not surprising when considering the fmily commitments of young mothers nd the distnces from our reserch center tht mny of our subjects lived. We were encourged to find tht our postprtum subjects were resonbly representtive of the nteprtum cohort from our initil study (Tbles S1 nd S2). An nlytic limittion ws not controlling for BMI differences mong our prticipnts. By focusing our nteprtum vs SLEEP, Vol. 36, No. 5, Follow Up of SDB in Gestionl Hypertension Reid et l

4 Estimted Men RDI (95% CI) Helthy Estimted Men RDI (95% CI) Gesttionl Hypertension Anteprtum Postprtum Anteprtum Postprtum Time Point Time Point Figure 1 Modelled men RDI of study prticipnts. Dt points represent the djusted men RDI of study prticipnts. CI, confidence intervl. Error brs = SEM. postprtum comprisons of helthy women nd women with GH seprtely we compred women with similr BMI mesurements, which incresed our confidence in our conclusions. Future studies would do well to ddress issues with BMI differences between GH nd helthy women during the design of the study, perhps mtching prticipnts bsed on BMI. Although there hve been few smll reports of SDB improving postprtum in women with known SDB, this is the first study we re wre of which compres women with GH nd helthy women in terms of sleep nd sleep relted brething chnges t the nteprtum nd postprtum time points. Clerly lrger nd longer term studies re needed in this re. CONCLUSION Despite persistent obesity, we found tht SDB in women with gesttionl hypertension improved in the postprtum stte to levels indistinguishble from our helthy subjects. This suggests tht the physiologic effects of pregnncy my hve hd pthologic role in the development of nteprtum SDB in women with GH. Women with GH my need to be followed for the reppernce of SDB with ging, s further physiologic chnges nd/or weight gin my gin unmsk propensity to SDB. Ultimtely, lrger nd longer-term follow-up studies re needed to clrify this issue. ACKNOWLEDGMENTS All reserch ws conducted t the Royl University Hospitl Sleep Disorders Centre, Ssktoon SK, Cnd. The uthors thnk Dr. Lis Lix of the University of Mnitob for her ssistnce with sttisticl evlution nd Mryl Stiles, Lori Reid, Joe Mink, s well s the stff in the Royl University Hospitl Sleep Lb nd Anteprtum Wrd. The uthors cknowledge the Ssktoon Helth Region for their support. This project ws jointly funded by the Ssktchewn Helth Reserch Foundtion, The Lung Assocition of Ssktchewn nd the University of Ssktchewn. The funding gencies hd no role in the cquisition, storge or interprettion of the dt. Dr. Reid hd full ccess to ll the dt in the study nd tkes full responsibility for the integrity of the dt nd ccurcy of the nlysis. DISCLOSURE STATEMENT This ws not n industry supported study. The uthors hve indicted no finncil conflicts of interest. REFERENCES 1. Robbins CL, Dietz PM, Bombrd J, Vlderrm AL. Gesttionl hypertension: neglected crdiovsculr disese risk mrker. Am J Obstet Gynecol 2011;204:336.e Cndin Hypertension Eduction Progrm. The 2008 Cndin Hypertension Eduction Progrm recommendtions: the scientific summry -- n nnul updte. Cn J Crdiol 2008;24: Frnklin KA, Holmgren PA, Jonsson F, Porom N, Stenlund H, Svnborg E. Snoring, pregnncy-induced hypertension, nd growth retrdtion of the fetus. Chest 2000;117: Reid J, Skomro R, Cotton D, et l. Pregnnt women with gesttionl hypertension my hve high frequency of sleep disordered brething. Sleep 2011;34: Chmpgne K, Schwrtzmn K, Optrny L, et l. Obstructive sleep pnoe nd its ssocition with gesttionl hypertension. Eur Respir J 2009;33: Edwrds N, Blyton DM, Hennessy A, Sullivn CE. Severity of sleep-disordered brething improves following prturition. Sleep 2005;28: McDonld SD, Mlinowski A, Zhou Q, Yusuf S, Devereux PJ. Crdiovsculr sequele of preeclmpsi/eclmpsi: systemtic review nd met-nlyses. Am Hert J 2008;156: Iber C, Ancoli-Isrel S, Chesson A, Qun S. The AASM mnul for the scoring of sleep nd ssocited events: rules, terminology nd technicl specifictions. Westchester, IL: Americn Acdemy of Sleep Medicine, SLEEP, Vol. 36, No. 5, Follow Up of SDB in Gestionl Hypertension Reid et l

5 9. Shpiro SS, Wilk MB. An nlysis of vrince test for normlity (complete smples). Biometrik 1965;52: Nelder JA, Wedderburn RW. Generlized liner models. J R Stt Soc Ser A 1972;135: Lwless J. Negtive binomil nd mixed Poisson regression. Cn J Stt 1972;15: Zeger SL, Ling KY. Longitudinl dt nlysis for discrete nd continuous outcomes. Biometrics 1986;42: SLEEP, Vol. 36, No. 5, Follow Up of SDB in Gestionl Hypertension Reid et l

6 SUPPLEMENTAL MATERIAL Tble S1 Anteprtum comprison of helthy women who did nd did not prticipte in the follow-up study No follow-up (n = 17) Follow-up (n = 7) Age (yer) 29.8 ± 3.4 (29.0) 29.9 ± 6.9 (32.0) 0.99 BMI (kg/m 2 ) 28.5 ± 5.0 (27.5) 28.8 ± 4.2 (27.2) 0.90 Gesttionl Age (weeks) 35.1 ± 1.9 (35.9) 33.4 ± 4.2 (34.0) 0.31 ESS 7.1 ± 2.8 (7.0) 11.0 ± 4.0 (10.0) 0.01 Snoring 4 (24%) 5 (71%) 0.03 c TST (min) ± 53.0 (315.0) ± 49.3 (309.0) 0.38 AHI (events/h) 0.3 ± 0.6 (0.0) 0.9 ± 2.4 (0.0) 0.71 b RDI (events/h) 2.4 ± 2.0 (2.0) 2.8 ± 5.3 (1.2) 0.27 b 24 complete PSGs for ssessment. t-test comprison of mens. b Mnn-Whitney U comprison of distribution. c Chi-squre test comprison of counts. BMI, body mss index; ESS, Epworth Sleepiness Scle; AHI, pne hypopne index; RDI, respirtory disturbnce index; TST, totl sleep time. Tble S2 Anteprtum comprison of GH women who did nd did not prticipte in the followup study No follow-up (n = 22) Follow-up (n = 11) Age (yer) 28.9 ± 6.0 (30.0) 27.9 ± 4.7 (27.0) 0.63 Gesttionl Age (weeks) 34.6 ± 3.3 (35.5) 34.7 ± 3.2 (35.7) 0.96 BMI (kg/m 2 ) 36.5 ± 7.5 (35.8) 37.6 ± 5.9 (36.2) 0.67 ESS 8.6 ± 3.3 (9.0) 6.3 ± 3.2 (5.0) 0.06 Snoring (yes/no) 18 (82%) 9 (82%) 1.00 c TST (min) ± 67.0 (291.5) ± 66.7 (242.0) 0.15 AHI (events/h) 2.2 ± 3.8 (0.4) 4.6 ± 9.3 (0.3) 0.95 b RDI (events/h) 10.7 ± 10.9 (5.2) 12.0 ± 12.3 (6.4) 0.92 b 33 Complete PSGs for ssessment. t-test comprison of mens. b Mnn-Whitney U comprison of distribution. c Chi-squre test comprison of counts. BMI, body mss index; ESS, Epworth Sleepiness Scle; AHI, pne hypopne index; RDI, respirtory disturbnce index; TST, totl sleep time. SLEEP, Vol. 36, No. 5, A Follow Up of SDB in Gestionl Hypertension Reid et l

7 Tble S3 Postprtum comprison of helthy vs. GH women Helthy (n = 7) GH (n = 11) Age (yer) 31.9 ± 6.9 (33.0) 29.7 ± 4.5 (28.0) 0.44 Follow-up time (months) 17.6 ± 2.8 (18.0) 17.1 ± 4.4 (16.0) 0.80 BMI (kg/m 2 ) 22.8 ± 4.0 (21.7) 32.5 ± 6.8 (32.3) < 0.01 ΔBMI (kg/m 2 ) -6.0 ± 1.4 (-5.5) -5.1 ± 3.4 (-5.5) 0.04 ESS 11.4 ± 4.1 (11.0) 6.3 ± 3.1 (5.0) 0.01 Arousl index (events/hour) 5.6 ± 4.7 (4.8) 6.0 ± 4.0 (6.1) 0.59 b Sleep Qulity VAS (%) 51.8 ± 25.0 (66.2) 49.0 ± 23.3 (41.9) 0.81 b Postprtum snoring (yes/no) 4 (57%) 5 (45%) 0.63 c TST (minutes) ± 42.0 (391.8) ± (408.0) 0.02 Sleep Efficiency (%) 88.2 ± 3.4 (88.4) 83.1 ± 16.6 (88.3) 0.86 b % Supine (%) 45.5 ± 31.6 (31.0) 36.5 ± 30.0 (35.9) 0.53 b % REM (%) 13.8 ± 3.8 (13.8) 13.9 ± 6.4 (13.1) 0.96 AHI (events/h) 1.1 ± 2.0 (0.3) 2.6 ± 2.7 (1.3) 0.26 b RDI (events/h) 2.1 ± 3.2 (1.2) 2.9 ± 2.9 (1.9) 0.75 b Men SpO 2 (%) 97.0 ± 0.8 (97.3) 96.6 ± 1.5 (96.7) 0.47 Min SpO 2 (%) 93.0 ± 3.7 (95.0) 91.1 ± 5.2 (93.0) 0.43 b t-test comprison of mens. b Mnn-Whitney U comprison of distribution. c Chi-squre test comprison of counts. BMI, body mss index; ΔBMI, chnge in body mss index; ESS, Epworth Sleepiness Scle; AHI, pne hypopne index; RDI, respirtory disturbnce index; TST, totl sleep time. Tble S4 Anteprtum comprison of helthy vs. GH who prticipted in postprtum follow-up Helthy (n = 7) GH (n = 11) Age (yer) 29.9 ± 6.9 (32.0) 27.9 ± 4.7 (27.0) 0.48 Gesttionl Age (weeks) 33.4 ± 4.2 (34.0) 34.7 ± 3.2 (35.7) 0.45 BMI (kg/m 2 ) 28.8 ± 4.2 (27.2) 37.6 ± 5.9 (36.2) < 0.01 ESS 11.0 ± 4.0 (10.0) 6.3 ± 3.2 (5.0) 0.01 Anteprtum Snoring (yes/no) 5 (71%) 9 (82%) 0.61 c Sleep qulity VAS (%) 52.1 ± 18.7 (53.2) 36.2 ± 14.9 (30.5) 0.09 b TST (minutes) ± 49.3 (309.0) ± 66.7 (242.0) 0.01 Sleep efficiency (%) 80.7 ± 9.2 (81.1) 60.4 ± 16.6 (61.6) 0.01 b % Supine (%) 22.3 ± 22.6 (10.7) 22.2 ± 26.0 (9.9) 0.47 b % REM (%) 15.2 ± 2.4 (15.5) 7.4 ± 5.1 (7.3) < 0.01 AHI (events/h) 0.9 ± 2.4 (0.0) 4.6 ± 9.3 (0.3) 0.21 b RDI (events/h) 2.8 ± 5.3 (1.2) 12.0 ± 12.3 (6.4) 0.03 b Arousl index (events/h) 10.3 ± 6.9 (7.4) 19.5 ± 14.8 (15.6) 0.06 b Men SpO 2 (%) 96.7 ± 1.3 (96.8) 95.7 ± 1.3 (96.0) 0.12 Min SpO 2 (%) 93.0 ± 2.8 (94.0) 90.7 ± 4.0 (93.0) 0.15 b Gesttionl Age (weeks) 33.4 ± 4.2 (34.0) 34.7 ± 3.2 (35.7) 0.45 t-test comprison of mens. b Mnn-Whitney U comprison of distribution. c Chi-squre test comprison of counts. BMI, body mss index; ESS, Epworth Sleepiness Scle; AHI, pne hypopne index; RDI, respirtory disturbnce index; TST, totl sleep time. SLEEP, Vol. 36, No. 5, B Follow Up of SDB in Gestionl Hypertension Reid et l