A new clinical practice guideline from the American College of Chest Physicians (CHEST) now recommends targeted screening for obstructive sleep apnea (OSA) during pregnancy, particularly for women with obesity, hypertensive disorders, diabetes, or a family history of the condition. The guidance addresses a significant evidence gap in managing OSA in pregnancy, which affects about 9% of the general pregnant population and rises in complicated pregnancies. The guideline’s emphasis on targeted screening reflects growing recognition that undiagnosed OSA can exacerbate pregnancy-related morbidities.
OSA during pregnancy is linked to serious risks, including hypertensive disorders, gestational diabetes, severe cardiovascular complications, ICU admissions, and adverse fetal or neonatal outcomes. The guideline was developed by an international panel using the PICO framework and GRADE methodology to assess evidence certainty. The review covered studies from MEDLINE/PubMed, Embase, and the Cochrane Library, with the most recent search update in January 2025. The systematic literature search began with an original query in October 2022, establishing a baseline evidence set before the pragmatic update.
For screening, CHEST suggests evaluating pregnant individuals, especially those with obesity, hypertension, diabetes, or a family history of OSA. Either pregnancy-specific or conventional screening tools can be used, though their accuracy is limited. Treatment decisions hinge on the apnea-hypopnea index (AHI) and clinical risk. Positive airway pressure (PAP) is prioritized for AHI scores of 15 or higher, regardless of symptoms or other health conditions. Both pregnancy-specific questionnaires and traditional tools are acceptable, yet each demonstrates only modest sensitivity in this population.
When AHI scores fall between 5 and 15, treatment should be considered based on symptoms, complications, or additional risk factors like hypertension or diabetes. For women already using fixed continuous PAP (CPAP) before pregnancy, the guideline recommends switching to automatic PAP (APAP) to accommodate airway changes and gestational weight gain. Lifestyle measures and close monitoring are advised for lower-risk or asymptomatic mild cases. Switching to APAP accommodates the progressive airway narrowing and weight gain that occur throughout gestation, allowing pressure to self-adjust.
Diagnosis does not require laboratory polysomnography (PSG) for every case. Home diagnostic testing is acceptable, though it may underestimate AHI. A negative home study with persistent clinical suspicion could warrant PSG, the gold standard for full evaluation. PAP remains the preferred treatment when therapy is indicated, with APAP favored over fixed CPAP for pregnant women already using it. Home-based devices increase testing reach, particularly in underserved settings.