The American College of Chest Physicians has released a new clinical practice guideline for obstructive sleep apnea in pregnancy, addressing a significant evidence gap in the screening, diagnosis, treatment, and postpartum reassessment of the condition. Obstructive sleep apnea affects approximately 9% of the general pregnant population and is more prevalent in complicated pregnancies.
The guideline conditionally recommends screening during pregnancy, particularly in cases with obesity, hypertensive disorders, diabetes, or a family history of obstructive sleep apnea. Positive airway pressure is prioritized when treatment is indicated, especially for an apnea-hypopnea index of 15 or higher, regardless of symptoms or comorbidities.
A multidisciplinary international panel systematically reviewed the evidence around nine questions using the PICO format and applied the GRADE framework to determine evidence certainty and recommendation strength. They used the MEDLINE/PubMed, Embase, and Cochrane Library databases, with an original search in October 2022 and a pragmatic update in January 2025.
The central limitation of the guideline is that all nine recommendations are conditional and supported by very low-certainty evidence. As a result, the guideline combines available evidence with expert consensus rather than establishing high-certainty standards of care. This approach is necessary due to the limited data available.
The American College of Chest Physicians suggests screening pregnant individuals for obstructive sleep apnea, with particular attention to higher-risk pregnancies involving obesity, hypertensive disorders, diabetes, or a family history of obstructive sleep apnea. Either pregnancy-specific or conventional screening tools can be used, although their predictive performance is suboptimal.
Treatment is framed around both the apnea-hypopnea index and clinical risk, with positive airway pressure prioritized. For an apnea-hypopnea index of 5 to 15, treatment should be considered when symptoms, sequelae, comorbidities, or additional risk factors such as hypertension or diabetes are present. They emphasize the importance of considering these factors when determining treatment.
In the context of pregnancy, it is essential to consider the potential consequences of untreated obstructive sleep apnea on both the mother and the fetus. Implementation of these guidelines may lead to better health outcomes for pregnant individuals with obstructive sleep apnea, as it emphasizes the importance of screening and treatment.
The guideline suggests building postpartum reassessment into the care pathway for pregnancy-diagnosed obstructive sleep apnea. The American College of Chest Physicians recommends reassessing obstructive sleep apnea after delivery because pregnancy-associated disease may persist or resolve.
Patients with obstructive sleep apnea diagnosed before pregnancy may not require retesting. Patients with severe pregnancy-diagnosed obstructive sleep apnea or persistent symptoms may reasonably continue treatment. The guideline identifies substantial research gaps, including validation and implementation of screening tools, effects and timing of treatment, positive airway pressure adherence, alternative therapies, and the natural history and optimal timing of postpartum testing. They highlight the need for further research in these areas.
Research gaps exist.