Predisposing factors of restless legs syndrome in pregnancy

Evaluation of the relationship between restless legs syndrome, mental status, and sleep disorders among Moroccan women during their third trimester of pregnancy

Background

Restless legs syndrome (RLS) is a motor disorder encountered during pregnancy and leads to psychological and sleep impairments. The latter seems to be non-restorative and its occurrence alters the quality of life of pregnant women. The objective of this study was to evaluate the prevalence of RLS and its relationship with both anxio-depressive symptoms and sleep disorders among a population of Moroccan pregnant women during their third trimester of pregnancy.

Methods

A cross-sectional study was conducted in a population of pregnant women in their third trimester (n=178) admitted to two health facilities in the city of Marrakech: Youssef Ibn Tachafine and Oasis. The face-to-face questionnaire was used to collect data including demographic and clinical characteristics, the four diagnostic criteria of RLS, the Pittsburgh Sleep Quality Index (PSQI), and the Hospital Anxiety and Depression Scale (HADS). Patients were divided into two groups RLS+ (women with RLS) and RLS- (women without RLS).

Results

The prevalence of RLS was 59.5%; this syndrome was more common in the ninth month (74.15%) compared with the seventh and eighth months. Sleep impairment, including sleep efficiency, was significantly higher in RLS+ than RLS- (P-value 0.05). Anxiety but not depression is significantly increased in RLS+ compared to RLS- (48.11% versus 38.8%, P = 0.000). There were no significant differences between RLS+ and RLS- in terms of socio-demographic and other clinical characteristics.

Conclusion

RLS is encountered during the prenatal period, with a higher prevalence in the last trimester. During this stage of pregnancy, women suffering from RLS were vulnerable to anxiety and sleep disorders. Prevention and early diagnosis of RLS could be a proactive healthcare management leading to better health outcomes and better conditions of pregnancy, which precedes childbirth.

Prevalence and factors associated with restless legs syndrome among pregnant women in middle-income countries: a systematic review and meta-analysis

Introduction

Restless legs syndrome (RLS) is a debilitating condition characterized by uncomfortable sensations in the legs, typically occurring during periods of rest or sleep. It is more prevalent during pregnancy and is linked to sleep disturbances, diminished quality of life, and pregnancy complications. However, previous studies yielded inconsistent findings among pregnant women in middle-income countries. Consequently, this systematic review and meta-analysis sought to determine the pooled prevalence of restless legs syndrome and its associated factors in these populations.

Method

A systematic review and meta-analysis was conducted on published studies from middle-income countries until May 2023. The review strictly adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant search terms were used to search for studies in PubMed, MEDLINE, EMBASE, and Google Scholar. Data extraction was performed using the Joanna Briggs Institute tool for prevalence studies. The meta-analysis was conducted using STATA 17 software, and heterogeneity was assessed using the I2 test, while publication bias was evaluated using Egger's test. Forest plots were also used to present the pooled prevalence and odds ratio (OR) with a 95% confidence interval (CI) using the random-effects model.

Result

This review included 22 studies from nine countries with a total of 17, 580 study participants. The overall pooled prevalence of RLS among pregnant women in middle-income countries was 13.82% (95% CI: 13.31, 14.32), and having low hemoglobin level (AOR: 1.68, 95% CI: 1.29, 2.18), history of RLS (AOR: 7.54, 95% CI: 3.02, 18.79), muscle cramps (AOR: 3.58, 95% CI: 1.21, 10.61), excessive day time sleepiness (AOR: 4.02, 95% CI: 1.34, 12.04), preeclampsia (AOR: 2.06, 95% CI: 1.28, 3.30), and taking prophylactic iron supplementation (AOR: 0.59, 95% CI: 0.50, 0.69) were the identified factors associated with it.

Conclusion

Generally, nearly one in every eight pregnant women in middle-income countries develop restless legs syndrome during pregnancy. Having low hemoglobin level, a history of RLS, muscle cramps, excessive daytime sleepiness, preeclampsia, and taking prophylactic iron supplementation were the identified factors associated with it. These findings underscore the importance of addressing the identified factors associated with RLS in order to effectively mitigate its occurrence among pregnant women.

The Prevalence, Severity, and Predictive Factors of Restless Legs Syndrome in Pregnancy

OBJECTIVES

 The current study aimed to search the prevalence and severity of restless legs syndrome (RLS) in pregnancy according to the three trimesters and predictive factors of RLS in pregnancy based on validated diagnostic tools and a thorough literature review.

METHODS

The cross-sectional descriptive study included 500 pregnant women without comorbidities who were interviewed face-to-face. Age, height, weight, week of pregnancy, smoking, alcohol, caffeine use, regular exercise, and lab test results from the last visit were all included in the data. Only women satisfying the RLS diagnostic criteria were given the Restless Legs Syndrome Rating Scale.

RESULTS

The prevalence of RLS was found to be 29.2% with the highest rate in the third trimester (64.4%). In all trimesters, low ferritin (first trimester: p = 0.004; second trimester: p < 0.001; third trimester: p < 0.001), folic acid (first trimester: p = 0.001; second trimester: p < 0.001; third trimester: p < 0.001), vitamin B12 (first trimester: p = 0.003; second trimester: p < 0.001; third trimester: p < 0.001), and hemoglobin (first trimester: p < 0.001; second trimester: p < 0.001; third trimester: p < 0.001) levels were associated with RLS. In the second and third trimesters, low magnesium (p < 0.001 and p < 0.001, respectively) and high creatinine (p = 0.027 and p < 0.001, respectively) levels were associated with RLS. Higher thyroid-stimulating hormone and free T4 levels were associated with RLS in the third trimester but not in the first and second trimesters (median: 2.4 vs. 2.1, p < 0.001; median: 1.5 vs. 1.2, p < 0.001). In the multivariate regression analysis, age (p = 0.034, OR: 1.060, 95% CI: 1.005-1.119), present BMI (p < 0.001, OR: 1.8884, 95% CI: 1.597-2.222), BMI before conception (p < 0.001, OR: 0.607, 95% CI: 0.513-0.718), gravida (p < 0.001, OR: 2.172, 95% CI: 1.547-3.049), low ferritin level (p < 0.001, OR: 6.396, 95% CI: 0.00744-0.010405), low vitamin B12 (p < 0.001, OR: 10.347, 95% CI: 0.00120-0.00176), low folate (p < 0.001, OR: 5.841, 95% CI: 0.00616-0.01240), RLS history before conception (p = 0.013, OR: 4.963, 95% CI: 1.402-17.57), and RLS family history (p < 0.001, OR: 7.914, 95% CI: 0.18760-0.31151) were found to be predictive factors for RLS in pregnancy.

CONCLUSION

More attention is needed to RLS during pregnancy to prevent or treat this syndrome.

Common sleep disorders in pregnancy: a review

In this review, we provide a comprehensive overview of common sleep disorders during pregnancy, including their characterization, prevalence, risk factors, and possible contribution to maternal and fetal outcomes. We conducted a quasi-systematic literature search of the MEDLINE database and identified 744 studies from 1991 through 2021, inclusive, that met our inclusion criteria. We synthesized the existing literature on sleep disorders during pregnancy and highlighted controversies, research gaps, and needed clinical developments. Our review covers a range of sleep disorders, including insomnia, obstructive sleep apnea, restless legs syndrome, and circadian rhythm disorders. We discuss the prevalence of these disorders in pregnancy and their potential impact on maternal and fetal health outcomes. We also explore the relationship between sleep disorders, pre-pregnancy comorbidities such as obesity, and pregnancy-related conditions such as gestational diabetes mellitus and preeclampsia. In addition to summarizing the existing literature on sleep disorders during pregnancy, we also highlight opportunities for further research in this area. We suggest that future studies should strive to employ validated and objective measurement tools for sleep disorders and prioritize utilization of longitudinal methods with participant follow-up through postpartum, mid-life, menopause, and beyond. We also put forward investigation into the impact of circadian rhythm disruption on reproductive physiology and early pregnancy outcomes as an area of important work. Overall, our review provides valuable insights on sleep and reproduction and into common sleep disorders during pregnancy and their potential impact on maternal and fetal health outcomes.

Determination of optimal 25-hydroxyvitamin D cutoff values for the evaluation of restless legs syndrome among pregnant women

STUDY OBJECTIVES

Vitamin D deficiency is associated with restless legs syndrome (RLS). However, a cutoff value for serum 25-hydroxyvitamin D (25[OH]D) level associated with RLS has yet to be clearly determined. We evaluated the association between 25(OH)D and RLS in pregnant women.

METHODS

Data from 203 pregnant women were evaluated using blood samples taken in the third trimester. Liquid chromatography-tandem mass spectrometry and ligand binding assays were used to measure 25(OH)D. RLS was diagnosed based on International Classification of Sleep Disorders, third edition, criteria. The cutoff value for serum 25(OH)D associated with RLS was explored using receiver operating characteristic (ROC) curve and classification and regression tree (CART) analyses.

RESULTS

The results of liquid chromatography-tandem mass spectrometry (x) and ligand binding assays (y) for serum 25(OH)D in the RLS (n = 35, 17.2%) and non-RLS (n = 168) groups showed a relationship of y = -2.65 + 0.08x . The RLS group showed lower serum 25(OH)D and folate levels. ROC curve and CART analyses revealed cutoff values of 10-12.7 ng/mL and 6.6-7.2 ng/mL for 25(OH)D and folate, respectively. Of the 5 women with RLS symptoms persisting at a moderate-to-severe level after delivery, 4 had 25(OH)D levels < 10 ng/mL and all had folate levels < 6 ng/mL.

CONCLUSIONS

Vitamin D and folate deficiency were associated with RLS in pregnant women and may be associated with persistent moderate-to-severe postpartum RLS symptomatology; it is essential to examine associations with RLS while accounting for measurement methods and assay systems.

CITATION

Miyazaki A, Takahashi M, Shuo T, Eto H, Kondo H. Determination of optimal 25-hydroxyvitamin D cutoff values for the evaluation of restless legs syndrome among pregnant women. J Clin Sleep Med. 2023;19(1):73-83.

Kalça ve Diz Osteoartritli Hastalarda Huzursuz Bacak Sendromunun Yaygınlığı ve Şiddeti

Amaç: Huzursuz bacak sendromunun (HBS) prevalansı, şiddeti, ağrı düzeyleri, uyku hijyeni ve yaşam kalitesinin kalça ve diz osteoartriti (OA) arasında farklılık gösterip göstermediğini araştırmak. Gereç ve Yöntem: 2 Ocak 2020 - 2 Haziran 2020 tarihleri arasında 55-75 yaşları arasında diz OA'sı olan 103 ve kalça OA'si olan 98 hasta dahil edilme ve dışlama kriterlerine göre kaydedildi. Ağrı şiddeti için visüel ağrı skalası (VAS), OA şiddeti için Lequesne şiddet indeksi, HBS semptomlarının sıklığı ve şiddeti ve uyku davranışları için Uyku Hijyeni İndeksi ve genel sağlığın değerlendirilmesi için Nottingham Sağlık Profili (NSP) kullanıldı. Bulgular: HBS semptom şiddeti, HBS süresi, VAS genel ve gece, uyku hijyen indeksi ve NSP uyku, enerji ve NSP Bölüm 1 ve Bölüm 2 parametreleri Diz OA'sında kalça OA'ya göre anlamlı olarak daha yüksekti. HBS şiddeti ile HBS süresi,vücut kitle indeksi ve Leq Hip skorları arasında güçlü bir pozitif korelasyon saptandı; ancak gece VAS'ı, uyku NSP'si ve fiziksel NSP parametreleri arasında zayıf bir korelasyon tespit edildi. HBS süresi ile uyku NSP'si, Leq diz OA şiddeti ve derecesi arasında güçlü bir pozitif korelasyon saptandı. Sonuç: HBS’li hastaların tedavi ve takibinde hastaların kilo kontrolü ile birlikte kalça ve diz OA tedavisinin de göz önünde bulundurularak takip edilmesinin hastaların yaşam kalitelerinin artırılmasına yardımcı olacağı öngürülmektedir.

Maternal Vitamin B12 Levels During Pregnancy and Their Effects on Maternal Neurocognitive Symptoms: A Systematic Review

OBJECTIVE

Vitamin B₁₂ deficiency has been linked to neurocognitive symptoms. Vitamin B₁₂ deficiency in pregnancy may be associated with antenatal or postpartum depression along with other neurocognitive symptoms including restless leg syndrome. The objective of this study was to systematically review the literature regarding vitamin B₁₂ deficiency and insufficiency in pregnancy and its effects on maternal neurocognitive symptoms.

DATA SOURCES

MEDLINE, Embase, and SCOPUS were searched from inception to October, 2020.

STUDY SELECTION

Observational studies and randomized controlled trials of singleton pregnancies involving vitamin B₁₂ deficiency and reporting maternal neurocognitive outcomes were identified.

DATA EXTRACTION AND SYNTHESIS

Data were synthesized and are presented narratively.

CONCLUSIONS

The 5 studies included in the analysis did not demonstrate a statistically significant link between vitamin B₁₂ deficiency or insufficiency and either restless leg syndrome or depression in pregnancy. To date, evidence is lacking that would support a causal link between suboptimal vitamin B₁₂ serum levels and maternal restless leg syndrome or depression.

Phenotypical predictors of pregnancy-related restless legs syndrome and their association with basal ganglia and the limbic circuits

Restless legs syndrome (RLS) in pregnancy is a common disorder with a multifactorial etiology. A neurological and obstetrical cohort of 308 postpartum women was screened for RLS within 1 to 6 days of childbirth and 12 weeks postpartum. Of the 308 young mothers, 57 (prevalence rate 19%) were identified as having been affected by RLS symptoms in the recently completed pregnancy. Structural and functional MRI was obtained from 25 of these 57 participants. A multivariate two-window algorithm was employed to systematically chart the relationship between brain structures and phenotypical predictors of RLS. A decreased volume of the parietal, orbitofrontal and frontal areas shortly after delivery was found to be linked to persistent RLS symptoms up to 12 weeks postpartum, the symptoms' severity and intensity in the most recent pregnancy, and a history of RLS in previous pregnancies. The same negative relationship was observed between brain volume and not being married, not receiving any iron supplement and higher numbers of stressful life events. High cortisol levels, being married and receiving iron supplements, on the other hand, were found to be associated with increased volumes in the bilateral striatum. Investigating RLS symptoms in pregnancy within a brain-phenotype framework may help shed light on the heterogeneity of the condition.

Zinc and Magnesium Levels of Pregnant Women with Restless Leg Syndrome and Their Relationship with Anxiety: A Case-Control Study

Restless leg syndrome (RLS) is a multifactorial movement disorder, and pregnancy is seen as a risk factor. This study aims to determine the clinical and psychiatric causes of RLS with a case-control study. The hemogram, biochemistry data, thyroid function tests, and serum element levels of healthy pregnant women (n = 134) and pregnant women diagnosed with RLS (n = 119) were compared. Total Ca, Mg, K, and Na concentrations were measured with an inductively coupled plasma optical emission spectrometry (ICP-OES), and an atomic absorption spectrophotometer was used to measure total concentrations of Zn in all samples. The Beck Anxiety Inventory (BAI), the Beck Depression Inventory (BDI), and the Pittsburg Sleep Quality Index (PSQI) scores were also compared in both groups. Sonographic measurements showed that the fetal biparietal diameter and femur lengths were higher in the RLS group (p = 0.001, p = 0.048, respectively), and abortion history was higher in the RLS group (p = 0.016). Magnesium and zinc levels were lower (p < 0.001 for both) and BAI and PSQI scores were higher (p < 0.001 for both) in the RLS group, and there was no difference between the BDI (p = 0.269) scores. A statistically significant relationship was detected between the BAI and RLS scores in the control and RLS groups (p < 0.001 for both). This is the first study to show that magnesium and zinc deficiency may play a role in the etiology of RLS during pregnancy; the results also showed adverse perinatal outcomes such as high miscarriage.

Prevalence of restless leg syndrome and effects on quality of life during pregnancy

PURPOSE

Restless leg syndrome (RLS) is a movement disorder which constitutes the most common and major risk group during pregnancy. The purpose of this study was to determine prevalence and severity of RLS during pregnancy and to investigate the effect of RLS on quality of life in pregnant women.

METHODS

This cross-sectional study was conducted in antenatal clinics of four different public hospitals. Data collected were pregnancy assessment form, RLS diagnostic criteria form, RLS severity scale, and SF-12 quality of life scale.

RESULTS

Among 718 pregnant women, mean age was 28.3±5.9 years (range 19 to 45). According to the diagnostic criteria of RLS, RLS prevalence was 22% (n=159). Of the 159 women with RLS, 41% had moderate severity and 40% had severe RLS. Prevalence of RLS in pregnant women increased with gestational week, working time during pregnancy, weight before pregnancy, total weight gain during pregnancy, and pre-pregnancy body mass index. Physical health scores, physical functioning scores, pain scores, emotional role difficulty scores, and social function scores were significantly lower in the pregnant women with RLS than without RLS (p <0.05).

CONCLUSIONS

Approximately one-fifth of the pregnant women had RLS, mostly in the third trimester, and the severity of RLS was predominantly moderate and severe. Pregnant women with RLS had poorer quality of life than pregnant women without RLS.

Is there a relationship between restless legs syndrome and medical problems in pregnant women? A cross-sectional study in Iran

This study aimed to assess the relationship between RLS and medical problems among pregnant women. In this study, 700 pregnant women were recruited. A socio-demographic questionnaire and the International Restless Legs Questionnaire were used to gather information. Data analyzed using an independent t test, Chi-square, and multivariate analysis. The prevalence of RLS was 28.9%. Women with hypertension were 1.90 times more probable to have RLS (adjusted OR 1.90, CI 1.14-3.19). Women with chronic hypertension and superimposed preeclampsia were 2.39 and 2.13 times more probable to experience RLS, respectively. Pre-eclamptic women were 1.87 times more probable to experience RLS. Women with diabetes, gestational diabetes and anemia have also been more likely to have RLS. Results of the present study show that there is a significant relationship between RLS and medical problems such as chronic hypertension, superimposed preeclampsia, gestational diabetes and anemia among pregnant women.

Prevalence of restless legs syndrome among pregnant women: A case-control study

BACKGROUND:

This cross-sectional case–control study aimed to assess the prevalence of restless legs syndrome (RLS) and its correlates and severity among Arab (Saudi) pregnant women attending antenatal care clinics.

METHODS:

We interviewed 742 consecutive pregnant women attending antenatal clinics face-to-face using the International RLS Study Group (IRLSSG) criteria. We assessed the severity of RLS using the IRLSSG severity scale for RLS (IRLS). A similar number of age-matched nonpregnant women were enrolled in a control group.

RESULTS:

Among the cases, 104 (14%) were in the first trimester, 232 (31.3%) in the second trimester, and 406 (54.7%) in the third trimester. The RLS prevalence in cases and controls was 30% and 26.5%, respectively, (P = 0.134). Among cases, severe/very severe RLS was diagnosed in 25% and mild/moderate in 75%, compared with 15% of controls having severe/very severe RLS and 85% having mild/moderate RLS (P < 0.001). Multivariate binary logistic regression analysis identified the following parameters as independent predictors of RLS: parity (odds ratio [OR] 1.113 [confidence intervals [CI] 1.012–1.223], P = 0.027), anemia (OR 1.452 [1.033–2.042], P = 0.03), diabetes mellitus (OR 1.734 [CI 1.084–2.774], P = 0.022), Vitamin D deficiency (OR 2.376 [CI 1.488–3.794],P < 0.001), and smoking (OR 3.839 [CI 1.463–10.074], P = 0.006). None of the cases had been diagnosed or treated for RLS in the antenatal clinics.

CONCLUSION:

RLS is common, but underdiagnosed, among Saudi pregnant women and nonpregnant women of childbearing age. The study revealed that RLS during pregnancy is linked to parity, anemia, diabetes mellitus, Vitamin D deficiency, and smoking.

Restless legs syndrome and quality of life in pregnant women

OBJECTIVE

In this study, we aimed to determine the extent of restless legs syndrome (RLS) in pregnant women and evaluate the relationship between the syndrome and quality of life.

METHODS

This is a cross-sectional descriptive study. A questionnaire developed by the researcher, the Short Form 36 (SF-36) Questionnaire to measure the quality of life, the International Restless Legs Syndrome Study Group (IRLSSG) Diagnostic Criteria for RLS and the Restless Legs Syndrome Rating Scale were applied to the women to collect the data. A total of 250 pregnant women were included in the study.

RESULTS

The mean age of the women was 28.11 ± 5.59 years and the mean gestational time was 26.26 ± 10.72 weeks. Symptoms of RLS were seen in 46.4 % of the women. The mean for the RLS Violence Rating Score was 20.82 ± 6.61 for the women with RLS. RLS was found to be mild in 5.2 % of the women, moderate in 45.7 %, severe in 40.5 % and very severe in 8.6 %. A statistically significant effect of RLS survival on quality of life was observed.

CONCLUSION

These results indicate that almost half of the pregnant women in this study experienced RLS, and about half of those with RLS experienced severe or very severe RLS. There is a significant relationship between RLS and six domains of SF-36 (physical, role limitations, pain, general health perception, energy/vitality, and mental health).

Management Strategies for Restless Legs Syndrome/Willis-Ekbom Disease During Pregnancy

Restless legs syndrome/Willis-Ekbom disease is a common disorder during pregnancy that may significantly impact on the health of affected women, leading to negative consequences in the short and long term. An accurate diagnosis helps to recognize the syndrome and choose the optimal therapeutic strategy, based on the characteristics and needs of the patient. This article summarizes the main treatment options recommended by the consensus clinical guidelines of the International Restless Legs Syndrome Study Group and provides a short guide to the management of restless leg syndrome during pregnancy in clinical practice.

The prevalence of restless leg syndrome among pregnant Saudi women

Objectives:

Restless legs syndrome (RLS) is common among pregnant women, but it has not been documented in pregnant Saudi Arabian women. The main purpose of this study was to estimate the extent of the prevalence of RLS and identify both the associated factors and the associated risk factors among pregnant Saudi women.

Methods:

A cross-sectional study was conducted among pregnant women visiting obstetric clinics at King Abdulaziz Medical City in Riyadh (KAMC-Riyadh) over the period from June 1 to November 1, 2014. We interviewed the participants and collected demographic data, number of pregnancies, duration of pregnancy, comorbidities, and symptoms of RLS. The diagnosis of RLS is based on the four criteria designated by the International RLS Study Group.

Results:

The total number of participants enrolled was 517, and the mean age was 30.11 ± 5.42 years. The prevalence of RLS was 21.3% (110/517) (95% confidence interval [CI]: 17.83%-25.06%). RLS symptoms were more common among women in the third trimester (24.1%) compared to the second trimester (14.3%) and first trimester (13.6%), P = 0.043. The stepwise multivariate logistic model identified insomnia (odds ratio [OR]: 3.6, 95% CI: 2.167–6.017, P = 0.001), and poor sleep quality (OR: 4.9, 95% CI: 1.473-16.454, P = 0.010) were associated with RLS.

Conclusion:

RLS occurs in two of ten pregnant women visiting obstetric clinics at KAMC-Riyadh and is strongly associated with insomnia and poor sleep quality. Studies are needed to explore the causality of these associations.

Use of α2δ Ligands for Restless Legs Syndrome/Willis Ekbom Disease

Restless legs syndrome is a common neurological condition affecting a substantial portion of the population. It can be an idiopathic disorder, or one that is secondary to another cause. Given that the underlying pathophysiology of restless legs syndrome is not well understood, several drug classes have been studied for symptom control. While dopamine agonists have long been the mainstay of first-line treatment for restless legs syndrome, recently, the α2δ ligands have been increasingly used. These agents have proven both efficacious and safe in a number of clinical trials. Additionally, compared with the dopamine agonists, they have been associated with less augmentation, a phenomenon whereby symptoms emerge earlier in the day, become more severe, and may spread to areas of the body previously unaffected. Newer clinical guidelines for restless legs syndrome are increasingly recommending the α2δ ligands as a logical first-choice medication for patients needing drug therapy for symptom control.

Improving Sleep for Hospitalized Antepartum Patients: A Non-Randomized Controlled Pilot Study

STUDY OBJECTIVES

To evaluate feasibility and efficacy of a hospital-based protocol for improving sleep in high- risk antepartum patients.

METHODS

Sleep measures were compared during 1 week of hospitalization before and after implementing a Sleep Improvement Protocol for Antepartum Patients (SIP-AP). A non-randomized convenience sample of usual care controls was compared to a subsequent intervention sample after the protocol was implemented. Women were eligible if they spoke English, were medically stable, pregnant for at least 20 weeks, and hospitalized at least 24 hours; 25 pregnant women had sufficient data for analyses (11 controls, 14 intervention). Sleep was assessed in 3 ways: the Pittsburgh Sleep Quality Index was completed after obtaining consent to estimate sleep quality prior to hospital admission; sleep diary completed each hospital day; and General Sleep Disturbance Scale completed at 7 days or prior to hospital discharge. Symptoms that could affect sleep were assessed with the Memorial Symptom Assessment Scale.

RESULTS

Both groups recorded similar sleep duration (7 hours) but the intervention group had fewer symptoms and significantly (P = .015) lower sleep disturbance scores (53.1 ± 14.5) than controls (71.9 ± 18.8). Participant feedback about the intervention was positive, although adherence to components of the intervention protocol was variable.

CONCLUSIONS

This pilot study provides evidence of the feasibility and preliminary efficacy of the SIP-AP intervention for reducing symptoms and improving sleep of antepartum patients during hospitalization. Further detailed evaluation of specific components of this protocol is warranted, and other types of hospitalized patients may benefit from unit-based modifications to this SIP-AP protocol.

Prevalence of restless legs syndrome during pregnancy: A systematic review and meta-analysis

Pregnant women are more likely to be affected by restless legs syndrome (RLS) than the general population. Restless legs syndrome during pregnancy is associated with adverse maternal and fetal outcomes. Currently unknown is the worldwide and regional prevalence of RLS in pregnant women. We performed a meta-analysis to provide a full profile of the prevalence of RLS during pregnancy. A systematic search of the PubMed, Medline, EMBASE, and Web of Science databases was performed to identify studies that were published up to April 2017, followed by random-effects meta-analyses. A total of 196 articles were identified, among which 27 longitudinal and cross-sectional observational studies with 51,717 pregnant subjects were included in the analysis. The pooled overall prevalence of RLS across all three trimesters was 21%. According to the regional classification of the World health organization, the prevalence of RLS during pregnancy in the European Region, Western Pacific Region, Eastern Mediterranean Region, and Region of the Americas was 22%, 14%, 30%, and 20%, respectively. The regional prevalence in the African Region and South-East Asia Region was not assessed because of insufficient data. We also analyzed the prevalence of RLS in the first, second, and third trimesters of pregnancy, and the rates of RLS were 8%, 16%, and 22%, respectively. We also found that the high prevalence of RLS decreased to 4% after delivery. No publication bias was found in these analyses. The findings emphasize the high occurrence of RLS during pregnancy. Future studies should examine the effects of RLS during pregnancy on maternal and fetal outcomes.

Restless Legs Syndrome and Sleep-Wake Disturbances in Pregnancy

STUDY OBJECTIVES

To estimate the association of restless legs syndrome (RLS) and its frequency with sleep-wake disturbances in pregnancy.

METHODS

A cohort of 1,563 women in their third trimester of pregnancy were recruited from prenatal clinics between March 2007 and December 2010. Demographic, pregnancy, and delivery data were extracted from medical records and sleep information was collected with questionnaires. To diagnose RLS, we used standardized criteria of RLS symptoms and frequency that were developed by the International Restless Legs Study Group. Logistic regression models were constructed to investigate the association of RLS and its frequency with sleep-wake disturbances (poor sleep quality, daytime sleepiness, poor daytime function) and delivery outcomes.

RESULTS

Overall 36% of the pregnant women had RLS, and half had moderate to severe symptoms. Compared to women without RLS, those with RLS were more likely to have poor sleep quality (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.7-2.9), poor daytime function (OR 1.9, 95% CI 1.4-2.4), and excessive daytime sleepiness (OR 1.6, 95% CI 1.3-2.0). A dose-response relationship also was evident between RLS frequency and each of the sleep-wake disturbances. There was no evidence for any association between RLS and delivery outcomes.

CONCLUSIONS

RLS is a significant contributor to poor sleep quality, daytime sleepiness, and poor daytime function, all common and often debilitating conditions in pregnancy. Obstetric health care providers should be aware of these associations and screen women for RLS.

COMMENTARY

A commentary on this article appears in this issue on page 857.

Managing Sleep Disorders during Pregnancy

Sleep disturbances and disorders are common during pregnancy, and they can be risk factors for a number of serious pregnancy-related sleep disorders. These include postpartum depression, pregnancy-induced hypertension, gestational diabetes, and intrauterine growth retardation. In addition, certain chronic sleep disorders, such as narcolepsy, are quite challenging to manage in the context of pregnancy and during lactation, particularly with medications that can be teratogenic. This review discusses 4 common sleep disorders and their impacts on pregnancy, and suggests ways to deal with these disorders that improves maternal and fetal outcomes safely. The review discusses diagnosis and treatment of obstructive sleep apnea, restless legs syndrome, insomnia, and narcolepsy in pregnancy.

Restless legs syndrome and pregnancy: prevalence, possible pathophysiological mechanisms and treatment

Restless legs syndrome (RLS) is a common sleep disorder that may be associated with pregnancy. Studies have found that the prevalence of RLS among pregnant women ranged from 10 to 34%. Typically, there is complete remission of symptoms soon after parturition; however, in some patients, they may continue postpartum. RLS has been shown to be associated with a number of complications in pregnancy including preeclampsia and increased incidence of Cesarean sections. Although multiple hypotheses have been proposed to explain this association, each individual hypothesis cannot completely explain the whole pathogenesis. Present understanding suggests that a strong family history, low serum iron and ferritin level, and high estrogen level during pregnancy might play important roles. Vitamin D deficiency and calcium metabolism may also play a role. Medical treatment of RLS during pregnancy is difficult and challenging considering the risks to mother and fetus. However, in some cases, the disease may be severe enough to require treatment.

Restless Legs Symptoms and Pregnancy and Neonatal Outcomes

PURPOSE

Restless legs syndrome (RLS) is a commonly occurring neurologic disorder that affects up to one third of women during pregnancy. RLS has been associated with increased sympathetic tone in the nonpregnant population. We examined whether a RLS surrogate is associated with a higher prevalence of pregnancy and neonatal outcomes.

METHODS

Data were analyzed from a cross-sectional survey of 1000 women interviewed soon after delivery by using an RLS surrogate question. Women were asked how frequently (0 = none, 1 = rarely [<1 time/week], 2 = sometimes [1-2 times/week], 3 = frequently [3-4 times/week], and 4 = always [5-7 times/week]) they had "experienced jumpy or jerky leg movements" in the last 3 months of pregnancy. Clinical charts were reviewed to obtain relevant demographic and clinical data, including the presence of gestational hypertensive disorders and neonatal outcomes at birth. Subjects who "always" experienced RLS were compared with subjects experiencing symptoms less frequently or not at all with respect to prevalence of gestational hypertensive disorder.

FINDINGS

The mean ([SD]) age, prepregnancy body mass index (BMI), and BMI at delivery were 29.0 (6.1) years, 26.1 (6.2) kg/m(2), and 32.0 (6.3) kg/m(2), respectively. The overall prevalence of the RLS surrogate (jumpy or jerky leg movements) was 35.5% with the following distribution on a Likert scale: score 1 = 6.4%; score 2 = 10.2%; score 3 = 8.1%; and score 4 = 10.8%. Chronic hypertension was present in 2.1%, pregnancy-induced hypertension in 9.5%, and preeclampsia in 4.5% of respondents. Subjects who reported "always" having sensations of jumpy or jerky legs were more likely to have gestational hypertensive disorders compared with those who reported less frequent occurrence of the symptoms. Adjusted odds ratios were 3.74 (95% CI, 1.31-10.72; P = 0.014) for chronic hypertension; 1.26 (95% CI, 0.65-2.46; P = 0.487) for pregnancy-induced hypertension; and 2.15 (95% CI, 0.97-4.75; P = 0.060) for preeclampsia. There was a significant association between leg movement score and neonatal birth weight (coefficient, -149.5 g [95% CI, -276.9 to -22.5]; P = 0.005) and gestational age at birth (-0.7 week [95% CI, -1.1 to -0.2]; P = 0.021) that persisted after adjusting for preeclampsia, diabetes, and smoking.

IMPLICATIONS

A higher frequency of jumpy or jerky leg symptoms, a proxy for RLS during pregnancy, was associated with a higher likelihood of gestational hypertensive disorders and neonatal outcomes such as gestational age at birth and birth weight. These findings may affect RLS treatment decisions during pregnancy.

Restless Legs Syndrome During Pregnancy and Preterm Birth in Women Referred to Health Centers of Ardabil

Background:

The physiological changes of pregnancy may predispose females to develop restless legs syndrome (RLS). Studies evaluating outcomes of RLS symptoms in pregnancy are scarce.

Objectives:

We examined the risk of preterm birth in pregnant women with and without restless legs syndrome (RLS).

Materials and Methods:

A cohort study included 231 pregnant women attending Ardabil health care centers for prenatal care and delivery in the period of 2010, without any risk factors for preterm delivery and low birth weight. The instruments used were questionnaires about RLS, the Epworth sleepiness scale (ESS), demographic data, and hemoglobin values. Data were analyzed via SPSS software using descriptive statistics, the t-test, χ2, Fisher’s exact test, Pearson’s correlation, and the Mann-Whitney U test.

Results:

RLS complicated 43.7 percent of pregnancies. Sleepiness (ESS score > 8) was reported in 36.4% of the subjects with preterm birth and 35.9% of the term group. No significant correlation was found between the ESS score and the term and preterm groups (P = 0.843). The prevalence of preterm birth in the subjects with and without RLS was 69.7% and 30.3%, respectively: As a result, it significantly increased in the RLS group (P = 0.001).

Conclusions:

Pregnancies complicated by RLS are at increased risk for preterm birth. The improved sleep health of pregnant women could decrease pregnancy complications.

Restless legs syndrome and pregnancy or delivery complications in China: a representative survey

OBJECTIVE

To perform a detailed epidemiological study of Chinese women and the relationship between restless legs syndrome (RLS) in pregnancy and any associated complications during delivery.

METHODS

A total of 3874 pregnant women (18-40 years) who had delivered babies at The First Affiliated Hospital of Zhengzhou University from May 2011 to May 2014 were enrolled in the study. Using a face-to-face interview questionnaire, data were collected pertaining to RLS incidence in pregnancy and any associated complications during delivery. The relationship between RLS frequency and pregnancy or delivery complications was further investigated.

RESULTS

Among 12.3% of the eligible participants, RLS prevalence occurred at least weekly. Older pregnant women were more likely to suffer from RLS. Individuals who experienced RLS at least weekly reported a statistically higher frequency of excessive daytime sleepiness and an increased prevalence of hypertension, cardiovascular disease, and preeclampsia compared with those without RLS.

CONCLUSION

The study revealed that RLS was frequent in Chinese pregnant women, especially in those with pregnancy or delivery complications such as hypertension, cardiovascular disease, and preeclampsia. Restless legs syndrome was also associated with excessive daytime sleepiness.

Restless legs syndrome and hypertension in Chinese pregnant women

Hypertension is a common complication of pregnancy, and studies show that pregnant women are more likely to suffer from restless legs syndrome (RLS). Pregnant women with hypertension and RLS often experience disrupted sleep patterns because of activation of the nervous system. The present study aimed to clarify the relationship between hypertension and RLS in pregnant women, and their impact on sleep. We enrolled 3,781 pregnant women who were admitted at our hospital for delivery between May 2011 and May 2014. The face-to-face questionnaire used to gather data included the International RLS Study Group criteria for diagnosis, Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and hypertension diagnosis. Depending on the time of occurrence of hypertension, it was divided into two different types: pregnancy-induced hypertension and chronic hypertension in pregnancy. Out of 3,781 patients, 453 fulfilled the diagnostic criteria for RLS and 486 met the diagnostic criteria for hypertension. Among patients with RLS, prophylactic iron supplementation was less frequently taken during pregnancy. Pregnancy-induced hypertension, rather than chronic hypertension in pregnancy, was found to be more frequent in patients with RLS; pregnant women with RLS had higher PSQI and ESS scores than pregnant controls. In our study, RLS was frequent in pregnant women, especially in those without prophylactic iron supplementation. Patients with RLS described more serious sleep disruption and excessive daytime sleepiness (EDS). In addition, pregnancy-induced hypertension was more common in patients with RLS.

Restless legs syndrome among pregnant women in China: prevalence and risk factors

BACKGROUND

The goal of this study was to identify the prevalence and clinical correlates and severity of restless legs syndrome (RLS) among pregnant women in mainland China.

METHODS

This cross-sectional study enrolled 1584 women (18-40 years old) who came to a prenatal outpatient clinic to consult an obstetrician. Pregnant women were studied in each trimester, and assessments included interviews about RLS symptoms and related questions. Standardized questionnaires include the International Restless Syndrome Scale and the Pittsburgh Sleep Quality Questionnaire. Blood tests included levels of hemoglobin and mean corpuscular volume.

RESULTS

RLS was diagnosed in 177 of 1584 women (11.2%); 4.2% were categorized as having pre-existing RLS and 54.8% reported onset of RLS symptoms after the 24th week. Multivariate analysis revealed that anemia was positively correlated with RLS. For the participants who first experienced RLS in pregnancy, RLS severity in the third trimester was more severe when compared with the first and second trimesters. Sleep disorders occurred more frequently in the third trimester.

CONCLUSIONS

In our study, RLS was frequent in pregnant Chinese women, and anemia was identified as an independent predictor of the disease. Further, most participants reported their symptoms during the third trimester, and the severity of RLS and sleep disorders of participants was more prominent in the third trimester.

Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis-Ekbom disease during pregnancy and lactation

Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) is common during pregnancy, affecting approximately one in five pregnant women in Western countries. Many report moderate or severe symptoms and negative impact on sleep. There is very little information in the medical literature for practitioners on the management of this condition during pregnancy. Accordingly, a task force was chosen by the International RLS Study Group (IRLSSG) to develop guidelines for the diagnosis and treatment of RLS/WED during pregnancy and lactation. A committee of nine experts in RLS/WED and/or obstetrics developed a set of 12 consensus questions, conducted a literature search, and extensively discussed potential guidelines. Recommendations were approved by the IRLSSG executive committee, reviewed by IRLSSG membership, and approved by the WED Foundation Medical Advisory Board. These guidelines address diagnosis, differential diagnosis, clinical course, and severity assessment of RLS/WED during pregnancy and lactation. Nonpharmacologic approaches, including reassurance, exercise and avoidance of exacerbating factors, are outlined. A rationale for iron supplementation is presented. Medications for RLS/WED are risk/benefit rated for use during pregnancy and lactation. A few are rated "may be considered" when RLS/WED is refractory to more conservative approaches. An algorithm summarizes the recommendations. These guidelines are intended to improve clinical practice and promote further research.

Sleep disorders: A review of the interface between restless legs syndrome and iron metabolism

Restless legs syndrome (RLS) is characterized by unpleasant sensations mainly in the legs. 43% of RLS-associated conditions have also been associated with systemic iron deficiency. The objective of this study was to review in the literature the relationship between iron metabolism and RLS. With an initial search using the keywords combination “Iron Metabolism OR Iron Deficiency AND Restless Legs Syndrome,” 145 articles were screened, and 20 articles were selected. Few studies were found for this review in the period of 2001–2014, however, the correlation between RLS and iron was evident.

Diagnosis, comorbidities, and management of restless legs syndrome

OBJECTIVE

This narrative review describes the differential diagnosis of restless legs syndrome, and provides an overview of the evidence for the associations between RLS and potential comorbidities. Secondary causes of RLS and the characteristics of pediatric RLS are also discussed. Finally, management strategies for RLS are summarized.

METHODS

The review began with a comprehensive PubMed search for 'restless legs syndrome/Willis-Ekbom disease' in combination with the following: anxiety, arthritis, attention-deficit hyperactivity disorder, cardiac, cardiovascular disease, comorbidities, depression, end-stage renal disease, erectile dysfunction, fibromyalgia, insomnia, kidney disease, liver disease, migraine, mood disorder, multiple sclerosis, narcolepsy, neuropathy, obesity, pain, Parkinson's disease, polyneuropathy, pregnancy, psychiatric disorder, sleep disorder, somatoform pain disorder, and uremia. Additional papers were identified by reviewing the reference lists of retrieved publications.

RESULTS AND CONCLUSIONS

Although clinical diagnosis of RLS can be straightforward, diagnostic challenges may arise when patients present with comorbid conditions. Comorbidities of RLS include insomnia, depressive and anxiety disorders, and pain disorders. Differential diagnosis is particularly important, as some of the medications used to treat insomnia and depression may exacerbate RLS symptoms. Appropriate diagnosis and management of RLS symptoms may benefit patient well-being and, in some cases, may lessen comorbid disease burden. Therefore, it is important that physicians are aware of the presence of RLS when treating patients with conditions that commonly co-occur with the disorder.

Sleep disorders in pregnancy

Sleep disturbances are common in pregnancy and may be influenced by a multitude of factors. Pregnancy physiology may predispose to sleep disruption but may also result in worsening of some underlying sleep disorders, and the de novo development of others. Apart from sleep disordered breathing, the impact of sleep disorders on pregnancy, fetal, and neonatal outcomes is poorly understood. In this article, we review the literature and discuss available data pertaining to the most common sleep disorders in perinatal women. These include restless legs syndrome, insomnia, circadian pattern disturbances, narcolepsy, and sleep-disordered breathing.

Iron in Restless Legs Syndrome

A link between restless legs syndrome (RLS) and iron has been recognized for several decades. Yet, the precise role that iron or other components of iron metabolism play in bringing about RLS is still a matter of debate. During the last few years, many new pieces of evidence from genetics, pathology, imaging, and clinical studies have surfaced. However, the way this evidence fits into the larger picture of RLS as a disease is not always easily understood. To provide a better understanding of the complex interplay between iron metabolism and RLS and highlight areas that need further elucidation, we systematically and critically review the current literature on the role of iron in RLS pathophysiology and treatment with a special emphasis on genetics, neuropathology, cell and animal models, imaging studies, and therapy.

Pre-pregnancy restless legs syndrome (Willis-Ekbom Disease) is associated with perinatal depression

OBJECTIVES

Both restless legs syndrome ([RLS], also known as Willis-Ekbom Disease [WED]) and depression are common during pregnancy. However, no prior studies have assessed if pregnant women with RLS have an elevated risk of depression during and/or after pregnancy.

METHODS

1,428 women who were pregnant in gestational week 16-17 were asked to participate in a longitudinal survey. They were followed by web-based questionnaires in gestational week 17 and 32, and 6 weeks after delivery. Data were also retrieved from prenatal and birth records. Two different sets of criteria were used to examine the prevalence of RLS in the cohort (International Restless Legs Syndrome Society Group standard criteria and the later developed CH-RLSQ11 questionnaire). The latter questionnaire attempts to exclude those with common "mimics" of RLS.

RESULTS

Adjusted odds ratio for depression in gestational week 17, 32, and postpartum week 6 in relation to pre-pregnancy RLS onset and moderate to severe symptom severity were 4.74 (2.30 - 9.76), 3.67 (1.85 - 7.28), and 2.58 (1.28 - 5.21), respectively. No significant associations were seen in pregnant women with de novo RLS during pregnancy. When using the standard diagnostic RLS criteria and frequency of symptoms more than 2-3 days per week, the prevalence of RLS was 12.3%. With the CH-RLSQ11 questionnaire and the same threshold for frequency of symptoms the prevalence was 6.5%.

CONCLUSION

Women with RLS onset before pregnancy with moderate or severe symptoms had an increased risk of both antenatal and postnatal depression. The self-reported prevalence of RLS during pregnancy is lower when a questionnaire dealing with "mimics" is used.

Restless legs syndrome and pregnancy: a review

Restless legs syndrome (RLS) is a common sensorimotor neurological disorder that is diagnosed according to the revised criteria of the International RLS Study Group (IRLSSG). The pathophysiology of RLS is still unknown and its prevalence is influenced by ethnicity, age, and gender. RLS is divided into two types by etiology: primary or idiopathic and secondary. Primary RLS is strongly influenced by a genetic component while secondary RLS is caused by other associated conditions such as end-stage renal disease or peripheral neuropathy. Another common condition associated with RLS is pregnancy. The prevalence of RLS during pregnancy is two to three times higher than in the normal population and is influenced by the trimester and the number of parity. The main mechanisms that may contribute to the pathophysiology of RLS during pregnancy are hormonal changes and iron and folate status. Standard medications for treating RLS during pregnancy are not established. Most medications have been used according to the evidence from non-pregnant patients. Therefore, consideration of the medical treatment for treating RLS during pregnancy should be balanced between the benefit of relieving the symptoms and maternal and fetal risk. In general, the prognosis of RLS during pregnancy is good and symptoms are usually relieved after delivery.

Gabapentin enacarbil for the treatment of moderate to severe primary restless legs syndrome (Willis-Ekbom disease): 600 or 1,200 mg dose?

Gabapentin enacarbil is a prodrug of the anticonvulsant gabapentin. The efficacy and safety of gabapentin enacarbil for the treatment of moderate to severe primary restless legs syndrome (RLS) has been evaluated in several clinical trials in the United States and Japan. Although most clinical trials assessed gabapentin enacarbil at doses greater than 600 mg/day and demonstrated the overall safety and efficacy (defined as improvements in the coprimary endpoints of the international RLS rating scale [IRLS] total score and Clinical Global Impression-Improvement response), the US Food and Drug Administration approved the 600 mg once-daily dosage because doses higher than 600 mg/day were considered to provide no additional benefits and were associated with higher rates of adverse events, such as somnolence and dizziness. Nonetheless, the results of clinical trials and post hoc meta-analyses have indicated that the 1,200 mg once-daily dosage was the most validated gabapentin enacarbil treatment for not only subjective RLS symptoms but also severe sleep disturbance associated with RLS. A Japanese dose-finding study showed that 900 mg/day, the intermediate dose between 600 and 1,200 mg, failed to show a significant improvement in IRLS total score, probably because many of the patients who discontinued treatment did so early, suggesting that a half-landing dose may cause more adverse effects than favorable ones in some RLS patients early in the treatment. Gabapentin enacarbil may have two distinct therapeutic doses for the treatment of RLS: 600 mg/day or lower doses for the treatment of subjective RLS symptoms and 1,200 mg/day or higher doses for the treatment of both subjective RLS symptoms and associated problems such as severe sleep disturbances.