Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Sleep studies for pregnant women who snore

  Snoring during pregnancy is often brushed off as a normal side effect of weight gain and fatigue. In reality, habitual snoring can signal underlying sleep-disordered breathing, including obstructive sleep apnoea, that deserves proper investigation. The louder and more frequent the snoring, the higher the chance of clinically significant nocturnal hypoxaemia.

  Pregnancy alters the upper airway through multiple mechanisms. Rising oestrogen and progesterone cause mucosal oedema and increased nasal resistance, while the enlarging uterus elevates the diaphragm. Weight gain across gestation further narrows the pharyngeal lumen, predisposing women to obstructive events when muscles relax during sleep.

  Yet snoring is rarely volunteered. Many expectant mothers across Australia, from Bondi to Brunswick, accept broken sleep as normal and never raise it with their midwife or GP. A simple question at the booking visit can change that.

  Australian maternity services are well placed to respond. With Medicare-funded antenatal care shared between GPs, midwives and obstetricians across public hospitals such as Royal Prince Alfred in Sydney, the Women's at Sandringham, the Mater in Brisbane and King Edward Memorial Hospital in Perth, there are multiple touch points where sleep history can be embedded.

  Snoring in pregnancy: more common than many realise

  Studies suggest habitual snoring affects 11 to 35 percent of pregnant women in the third trimester, compared with 4 to 7 percent of non-pregnant women of similar age. The drivers are physiological: capillary engorgement of the nasal mucosa produces rhinitis in up to 40 percent of pregnancies, leading to mouth breathing and vibration of the soft palate. Add 10 to 15 kilograms of weight gain and the gravid uterus pushing on the diaphragm, and the airway becomes genuinely compromised during sleep.

  Women frequently normalise the symptom. Comments such as "my partner says I sound like a chainsaw" are laughed off in antenatal classes, yet the same finding in a male patient would prompt an urgent sleep referral. That bias needs to change.

  The hidden cardiovascular and metabolic risks

  Women who snore habitually have roughly double the odds of developing gestational hypertension, with even stronger links to pre-eclampsia when snoring predates 20 weeks or is associated with witnessed apnoeas. Glucose metabolism is also affected: repeated arousals and intermittent hypoxia worsen insulin resistance, and cohort studies show higher rates of gestational diabetes independent of pre-pregnancy BMI.

  Fetal outcomes are not spared. Chronic nocturnal hypoxia and maternal blood pressure spikes are linked to fetal growth restriction, lower birth weight and, in some studies, increased rates of preterm birth.

  Red flags worth screening for at the first antenatal visit

  Screening is straightforward. Tools such as the STOP-BANG questionnaire and the Epworth Sleepiness Scale translate well into pregnancy with minor adjustments. Loud habitual snoring more than three nights a week, witnessed apnoeas, morning headaches and excessive daytime sleepiness should all trigger further assessment.

  Anatomical clues also help. A neck circumference above 40 centimetres, a crowded Mallampati score of 3 or 4 and a booking BMI in the overweight or obese range independently raise the pre-test probability of obstructive sleep apnoea. Australian GPs providing shared antenatal care can incorporate these questions into routine visits at 16, 28 and 36 weeks. Many already use templates that include mental health screening; adding a brief sleep module takes only a couple of minutes.

  Choosing the right diagnostic test

  Full laboratory polysomnography remains the reference test, capturing electroencephalogram, respiratory channels, leg movements and oxygen saturation, and is invaluable in high-risk pregnancies where overlap syndromes are suspected. For many women, a home sleep apnoea test offers a practical alternative. Australian guidelines from the Australasian Sleep Association support validated level 3 devices in uncomplicated pregnancies with a high pre-test probability of moderate to severe obstructive sleep apnoea.

  Devices can be mailed to regional centres such as Cairns, Dubbo or Burnie and scored centrally, helping rural women access diagnosis without travelling to tertiary sleep clinics. Bulk-billed options exist under Medicare, though public waiting lists can stretch beyond three months.

  Treatment considerations during pregnancy

  Continuous positive airway pressure remains first-line treatment for obstructive sleep apnoea in pregnancy. CPAP reduces nocturnal blood pressure, improves oxygenation and, in randomised trials, has been associated with better fetal movement counts and reduced rates of pre-eclampsia in adherent users.

  Adherence can be challenging. Nasal congestion responds to saline rinses and physician-approved topical steroids, and mask fit should be reviewed regularly through pregnancy as facial oedema alters seal. Pressure requirements often rise in the third trimester, requiring close coordination between the sleep physician, obstetrician and midwife. Avoiding supine sleep in late pregnancy complements CPAP and reduces both obstructive events and supine hypotension syndrome.

  Embedding sleep medicine into Australian antenatal pathways

  The Australian health system offers several entry points for integrating sleep assessment into routine pregnancy care. GP shared care arrangements, common in cities such as Adelaide and Hobart, allow ongoing screening without extra hospital visits, and midwifery-led models can include sleep questionnaires at routine contacts.

  Tertiary centres are leading the way. The Royal Women's Hospital in Melbourne runs combined obstetric-sleep clinics for high-risk women, with comparable services at the Mater Mothers' Hospital in Brisbane and the Women's and Children's Hospital in Adelaide. Telehealth has further reduced barriers: women in Tamworth, Broome or Mount Gambier can attend specialist video appointments, receive a home sleep apnoea test by post and start CPAP without leaving town. For a country as vast as Australia, this model is essential for equitable care.

  Practical steps for clinicians when pregnancy snoring is reported

  • Ask about snoring frequency, loudness and witnessed apnoeas at every routine antenatal visit
  • Use the STOP-BANG questionnaire alongside the Epworth Sleepiness Scale at booking
  • Refer for laboratory polysomnography when symptoms are severe, atypical or coexist with hypertension
  • Offer a Medicare-funded home sleep apnoea test for rural and remote women with high pre-test probability
  • Liaise early with a sleep physician when initiating CPAP during pregnancy
  • Monitor blood pressure, fetal growth and glucose more closely in confirmed sleep apnoea
  • Reassess sleep-disordered breathing postpartum if hypertension or weight retention persist

  The takeaway for clinicians is straightforward. Snoring in pregnancy is not a trivial symptom, and Australian maternity services have the tools to respond. With structured screening, timely access to sleep studies and coordinated CPAP therapy where indicated, the burden of gestational sleep-disordered breathing can be substantially lowered. Embedding a brief sleep history into standard antenatal visits offers one of the simplest evidence-based steps available to improve outcomes for both mothers and their babies.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)