I commend O’Brien et al for drawing attention to a potentially dangerous yet overlooked clinical condition in pregnancy in the article entitled, “Pregnancy-onset habitual snoring, gestational hypertension, and preeclampsia: prospective cohort study.” Particularly interesting is the observation that pregnancy-onset habitual snoring or what I term “gestational obstructive sleep apnea (OSA)” may be more problematic then superimposed OSA. The opportunity for intervention trials to determine a treatment effect on pregnancy-induced hypertension and preeclampsia is evident; however, the results of such trials should not cloud the fact that, once the patient with snoring is diagnosed definitively with clinically significant OSA, she should be treated effectively. I fear that the decision to treat might be held to the standard of statistically reducing the incidence of pregnancy-induced hypertension and preeclampsia. It is rare when such a simple intervention can solve complex problems, but it does happen occasionally.

Regardless, the patients who experience OSA must be treated, and I can think of no reason to withhold treatment. Continuous positive airway pressure is the treatment of choice and has been demonstrated to be safe, effective, and well tolerated in pregnancy. Similar to the general population, pregnant patients with severe sleep apnea (apnea-hypopnea index, >30/hr) and patients with an apnea-hypopnea index of 5-30/hr with daytime somnolence or high blood pressure certainly should be treated. The goal should be to abolish maternal oxyhemoglobin desaturation <90%.

Gestational OSA has been reported to improve and even resolve after delivery. The transient nature of the condition is quite likely because 75-80% of gestational weight gain is lost in 2-6 weeks after delivery, and weight loss may continue for up to 6 months. The current service model does not accommodate the speed and skill necessary to set pregnant patients up on continuous positive airway pressure. So, once a patient is identified, the practical challenge remains to get them objectively diagnosed, on CPAP at therapeutic pressure, and to accept therapy and to keep them adherent throughout the course of the pregnancy.