Sleep During Pregnancy: Disturbances, Disorders, Diagnosis & More
Quick Summary
Sleep disturbances are extremely common during pregnancy, affecting 66% to 97% of women, and tend to worsen as the pregnancy progresses, especially in the third trimester.
The primary causes of sleep problems are the significant hormonal, physical, and physiological changes the body undergoes to support the growing fetus.
Specific sleep disorders like insomnia, restless legs syndrome (RLS), sleep-disordered breathing (SDB), and nocturnal heartburn can begin or become more severe during pregnancy.
Poor sleep quality and inadequate sleep duration are not just uncomfortable; they are linked to serious health risks for both mother and baby, including gestational diabetes, preeclampsia, preterm birth, and stillbirth.
An Overview of Sleep Disturbances During Pregnancy
Sleep disturbance during pregnancy is a widespread and complex issue, with many different causes.
As a pregnancy advances, sleep becomes significantly more disturbed, particularly by the third trimester (Hedman et al., 2002; Facco et al., 2010; Izci-Balserak et al., 2018).
These sleep problems can stem from a variety of internal and external factors that alter the length or quality of a normal sleep pattern. The body undergoes profound physical, hormonal, and psychological changes at different stages of pregnancy, all of which can affect the degree and severity of sleep disturbances.
In some cases, these pregnancy-related changes can trigger new sleep disorders or worsen existing ones, which can have a considerable impact on both maternal and fetal health.
That makes it important to understand and identify significant sleep problems in pregnancy and get the right support to help reduce or prevent negative outcomes for both mother and child.
But what exactly do we mean by sleep disturbance in pregnancy?
What Is a Sleep Disturbance During Pregnancy?
A sleep disturbance during pregnancy refers to any issue that results from internal and external factors changing the duration, structure, or timing of a normal sleep pattern and the body's internal clock, known as the circadian rhythm.
Sleep disturbances can range from mild, temporary difficulties sleeping to clinically diagnosed sleep disorders.
The changes that are driven by the unique demands of pregnancy. The body’s hormonal shifts, physical growth of the uterus, and psychological adjustments all contribute to disrupting the normal sleep-wake cycle. This can mean you have difficulty falling asleep, waking up frequently during the night, or not feeling rested upon waking.
While some level of sleep change is expected during pregnancy, a significant disturbance goes beyond typical discomfort and can impact daytime functioning and overall health.
So, just how many expectant mothers experience these issues?
How Common Are Sleep Disturbances During Pregnancy?
Sleep disturbances during pregnancy are very common. Studies show that the majority of women, between 66% and 97%, experience significant changes in their sleep patterns (Christian et al., 2019; Facco et al., 2010; Wilson et al., 2011). These problems tend to become more frequent and severe as the pregnancy progresses.
Certain sleep disorders also become much more prevalent during this time:
Insomnia: Approximately 50% to 74% of women report symptoms of insomnia during pregnancy, with these symptoms being clinically significant - meaning they are severe enough to need medical attention - in 17% to 30% of cases (Facco et al., 2010; Fernandez-Alonso et al., 2012; Sivertsen et al., 2015). The prevalence of insomnia symptoms increases dramatically from pre-pregnancy levels (around 6%) to 44% in the first trimester and over 63% in the third trimester (Román-Gálvez et al., 2018).
Sleep-Disordered Breathing (SDB): This condition, which includes obstructive sleep apnea (OSA), also becomes more common. One large study using objective in-home sleep testing found that SDB was present in 3.5% of women in early pregnancy and increased to 8.2% by mid-pregnancy (Facco et al., 2017).
Restless Legs Syndrome (RLS): This condition is two to three times more common in pregnant women than in nonpregnant women (Manconi et al., 2012). A recent meta-analysis reported that RLS symptoms affect about 8% of women in the first trimester, 16% in the second, and 22% in the third (Chen et al., 2018).
Nocturnal Gastroesophageal Reflux (GERD): Symptoms of GERD, or heartburn, can affect 30% to 80% of women at some point during pregnancy (Van der Woude et al., 2014). One study found the prevalence of symptoms doubled from 26% in the first trimester to 51% in the third (Malfertheiner et al., 2012).
Given how common these issues are, what are the underlying factors that cause them?
What Causes Sleep Disturbances During Pregnancy?
The causes of sleep disturbances during pregnancy are a combination of dramatic hormonal shifts and significant physical changes that are essential for a healthy pregnancy but can interfere with sleep.
Hormonal Changes
Pregnancy triggers major fluctuations in several key hormones that directly and indirectly influence sleep.
Progesterone: Levels of this hormone released from the placenta can be 10 to 500 times higher by the end of pregnancy (Cunningham et al., 2018). Progesterone has a sleep-inducing effect, which may explain the daytime sleepiness common in the first trimester. It also relaxes smooth muscles, which can lead to more frequent urination and heartburn, and it increases breathing rates.
Estrogen: This hormone also increases significantly, peaking just before birth (Cunningham et al., 2018). It contributes to nasal congestion and fluid retention (swelling), which can make breathing more difficult and narrow the upper airway.
Physical and Physiological Changes
Beyond hormones, the physical transformation of the body creates numerous challenges for sleep.
Respiratory Changes: Increased levels of estrogen and progesterone cause swelling and mucus production in the upper airway, leading to nasal congestion, sometimes called 'pregnancy rhinitis,' which is stuffiness caused by hormones rather than a cold or allergies, and affects up to 40% of women by the third trimester (Dzieciolowska-Baran et al., 2013). This congestion, along with weight gain and fluid retention in the neck and tongue, can narrow the airway and increase the risk of snoring and sleep-disordered breathing.
Musculoskeletal Changes: The growing weight of the uterus shifts the center of gravity, leading to an exaggerated curve in the lower spine. Ligaments in the pelvis become more flexible to prepare for birth. These changes, along with fluid retention, frequently cause backache, pelvic pain, and leg cramps that worsen at night.
Urogenital and Gastrointestinal Tract Changes: The growing uterus puts pressure on the bladder, leading to frequent urination. This pressure, combined with the relaxing effect of progesterone on the digestive system, also displaces the stomach and can cause gastroesophageal reflux (heartburn).
Weight Gain and Fluid Volume: The average weight gain and the minimum 6.5 liters of extra fluid accumulated during pregnancy can lead to swelling in the legs and ankles. When lying down, this fluid can shift toward the neck, potentially worsening airway narrowing.
What Are the Risks That Make Sleep Problems More Likely During Pregnancy?
Certain factors can make a woman more likely to experience severe sleep problems:
Age and Parity: Being older than 30 and having no prior birthing experience (nulliparity) are associated with a higher risk for self-reported poor sleep quality (Hedman et al., 2002; Facco et al., 2010).
Higher Body Mass Index (BMI): A higher pre-pregnancy BMI is a known risk factor for developing sleep-disordered breathing during pregnancy (Louis et al., 2018).
Pre-existing Conditions: A history of depression or other affective disorders before pregnancy is a risk factor for insomnia (Dorheim et al., 2014). Chronic hypertension is also a risk factor for SDB.
Lifestyle and Environmental Factors: Smoking and environmental noise from other children or a bed partner can contribute to poor sleep (Mindell et al., 2015; Fernandez-Alonso et al., 2012).
With all these contributing factors, what specific signs and symptoms might a pregnant woman notice?
What Are the Signs And Symptoms of Sleep Disturbances During Pregnancy?
The signs and symptoms of sleep disturbances change and evolve with each stage of pregnancy, driven by the different hormonal and physical challenges of each trimester.
First Trimester (Weeks 1-12)
During the first trimester, dramatic hormonal shifts are the primary cause of sleep issues. Common symptoms include:
Daytime fatigue and sleepiness: Rising progesterone levels have a sedative effect, leading to profound fatigue.
More total sleep, but poorer quality: Women often sleep more over a 24-hour period due to napping, but night-time sleep is less refreshing.
Difficulty falling asleep and staying asleep: It may take longer to fall asleep, and waking up during the night becomes more common.
Frequent awakenings: These are often caused by the need to urinate, nausea or "morning sickness," tender breasts, and back pain.
Second Trimester (Weeks 13-26)
For many women, sleep improves during the second trimester as hormone levels stabilize. However, new challenges begin to emerge toward the end of this period:
Increased awakenings: As the uterus grows rapidly, physical discomfort increases.
New sources of disruption: Fetal movements, snoring, heartburn, and leg cramps can begin to disturb sleep.
Vivid dreams: Many women report experiencing more vivid dreams during this time.
Third Trimester (Weeks 27-40)
This is the period when sleep is most disturbed, with 75% to 98% of women reporting significant sleep problems (Hedman et al., 2002; Mindell et al., 2015). Symptoms include:
Frequent and prolonged awakenings: It becomes very difficult to get a consolidated block of sleep.
Low sleep efficiency: A high percentage of time spent in bed is actually spent awake.
Habitual snoring: The prevalence of snoring three or more nights a week increases from around 7-11% in early pregnancy to 16-25% in the third trimester (Facco et al., 2010; O'Brien et al., 2012; Sarberg et al., 2014). This can be a sign of sleep-disordered breathing.
Major physical discomfort: The large uterus makes finding a comfortable position difficult. Frequent urination, heartburn, leg cramps, and shortness of breath are common complaints.
Anxiety and vivid dreams/nightmares: Worries about labor, delivery, and the baby's health can interfere with sleep.
If these symptoms become severe, how do healthcare providers determine the cause?
How are Sleep Disorders During Pregnancy Diagnosed?
Diagnosing a sleep disorder during pregnancy requires a careful evaluation to distinguish between the normal discomforts of pregnancy and a more serious, underlying condition. The process often begins with a detailed discussion of a woman's sleep history and symptoms.
Insomnia: The diagnosis involves a clinical interview and sleep diaries determining that a woman has an adequate opportunity to sleep but is unable to fall or stay asleep. This is different from sleep disruption caused by physical discomforts like frequent urination, where the ability to fall back asleep is usually intact.
Restless Legs Syndrome (RLS): This is typically a clinical diagnosis based on a set of four main criteria related to the urge to move the legs. A provider will also evaluate for iron and folate deficiencies, as these are common contributing factors in pregnancy.
Sleep-Disordered Breathing (SDB): If SDB is suspected based on symptoms like loud snoring, gasping, or witnessed pauses in breathing, a provider will evaluate risk factors like age and BMI. A definitive diagnosis is made with a sleep study. This can be done in a formal sleep laboratory with a polysomnography test, which is a comprehensive overnight study that records brain waves, breathing, and other body functions. Another option is a home sleep apnea test, a simpler device you use in your own bed to monitor your breathing during sleep (Kapur et al., 2017).
Why is getting an accurate diagnosis and managing these conditions so critical?
What Health Problems Are Linked to Sleep Disturbances During Pregnancy?
Untreated sleep disorders and extremes of sleep duration are not just sources of discomfort; they are potential contributors to serious health problems for both the mother and the fetus.
What Are Potential Maternal Health Consequences From Pregnancy Sleep Disorders?
Pregnancy-Induced Hypertension and Preeclampsia: Both short sleep (less than 6 hours) and long sleep (more than 9 hours) in early pregnancy have been associated with elevated blood pressure in the third trimester (Williams et al., 2010). SDB specifically has been shown to increase the odds of developing preeclampsia - a serious high blood pressure disorder that can occur during pregnancy—by about twofold (Facco et al., 2017).
Gestational Diabetes Mellitus (GDM): Short sleep is linked to an increased risk of developing gestational diabetes (GDM), a type of diabetes that develops during pregnancy. One meta-analysis found that sleeping 6.25 hours or less per night was associated with a 2.84-fold increase in GDM risk (Reutrakul et al., 2018). SDB is also a significant risk factor; one study found that women with SDB in early or mid-pregnancy had a roughly threefold increased risk of developing GDM (Facco et al., 2017).
Adverse Labor Outcomes: Women in their last month of pregnancy who slept less than 6 hours per night had significantly longer labors and were 4.5 times more likely to have a cesarean delivery compared to those sleeping 7 hours or more (Lee & Gay, 2004).
What Are Fetal and Newborn Consequences Of Pregnancy Sleep Disorders?
Preterm Birth: Short sleep duration is associated with an increased risk of preterm birth (Micheli et al., 2011). Poor sleep quality is also a predictor, particularly among African-American women (Blair et al., 2015).
Fetal Growth and Birth Weight: Maternal sleep is important for fetal growth, as growth hormone secretion and blood flow to the placenta are highest during sleep. Some studies have shown that sleeping less than 7 or 8 hours per night is linked to an increased risk of having a baby that is small for gestational age (SGA), which means the baby weighs less than expected for the number of weeks of pregnancy (Abeysena et al., 2009; Wang et al., 2017).
Stillbirth: A growing body of evidence suggests a strong link between a mother's sleeping position and the risk of late-gestation stillbirth (at 28 weeks or later). An analysis of multiple studies found a 2.6-fold increased risk for stillbirth among women who reported going to sleep on their back (supine position) (Cronin et al., 2019). This is thought to be because the weight of the heavy uterus can compress major blood vessels, reducing blood flow to the baby.
Beyond these major health issues, how does poor sleep affect a woman's day-to-day experience?
How Do Sleep Disturbances During Pregnancy Affect Daily Life?
The accumulated sleep loss that is common during pregnancy can have a significant impact on a woman's energy levels, mood, cognitive function, and overall quality of life.
Poor and short sleep during pregnancy is consistently associated with worse mood and mental health. Depressive symptoms are strongly linked to insomnia in late pregnancy, especially when sleep duration is very short (less than 5 hours) or very long (more than 10 hours) (Dorheim et al., 2012).
Poor sleep in early pregnancy can also predict the development of depressive symptoms later in the pregnancy and even three months postpartum (Pietikäinen et al., 2019).
Functionally, persistent sleep loss is likely to interfere with a pregnant woman’s ability to work efficiently due to fatigue and sleepiness. This can lead to higher rates of absenteeism from the workplace and increases the risk for accidents, both at work and while driving.
The effects on concentration and memory can also be frustrating and add to the stress of preparing for a new baby.
Given these wide-ranging effects, what can be done to treat these conditions?
How Are Sleep Disturbances During Pregnancy Treated?
The primary goal of treatment is to improve sleep and well-being while ensuring the safety of both the mother and the developing fetus. For this reason, non-pharmacologic therapies - meaning treatments that do not involve medication - are always the first-line approach.
How Is Pregnancy Insomnia Treated?
The most effective and recommended treatment is Cognitive Behavioral Therapy for Insomnia (CBT-I). This is a structured program that helps you identify and replace behaviours, thoughts and emotional reactions that cause or worsen sleep problems. CBT-I is not the same as sleep hygiene advice often found on the internet. A large randomized controlled trial confirmed that CBT-I significantly reduces insomnia severity in pregnant women (Manber et al., 2019). It is the preferred treatment option for the majority of expecting couples (Sedov et al., 2019).
How Is Restless Legs Syndrome (RLS) During Pregnancy Treated?
Initial treatment focuses on non-medication strategies like gentle walking or stretching before bed, massaging the affected limbs, and applying heat. Since RLS in pregnancy is often linked to low iron or folate levels, your doctor may recommend supplements after checking your bloodwork.
How Is Nocturnal Gastroesophageal Reflux (GERD) During Pregnancy Treated?
Simple lifestyle changes can be very effective. These include avoiding large meals within 3 hours of bedtime, eating smaller, more frequent meals, and avoiding spicy or acidic foods. Elevating the head of the bed and sleeping on the left side can also help. If these changes are not enough, antacids are often effective and have a low risk of harm to the fetus (Van der Woude et al., 2014).
How Is Sleep-Disordered Breathing (SDB) During Pregnancy Treated?
The primary medical treatment for SDB is Continuous Positive Airway Pressure, or CPAP. This therapy involves a small machine that delivers a gentle, steady stream of air through a mask you wear over your nose or mouth, keeping your airway open while you sleep. CPAP is considered safe and effective for use during pregnancy (Guilleminault et al., 2004; Poyares et al., 2007). However, there are therapies beyond CPAP. For example positional therapy, which involves using pillows or other devices to help you stay on your side, can also be a helpful addition to treatment if OSA primarily occurs when sleeping on one’s back.
What are some practical steps you can take to manage sleep problems at home?
Tips for Living Well With Sleep Disturbances During Pregnancy
While some sleep disruption is a normal part of pregnancy, there are many practical steps you can take to improve your sleep quality and manage discomfort (note: these tips are not the same as treatment)
Prioritize a Consistent Sleep Schedule: Go to bed and wake up around the same time each day, even on weekends. This helps regulate your body's internal clock.
Keep daytime naps short: Long daytime naps (greater than 20mins) can disrupt nighttime sleep so keeping naps short promotes consolidated nightime sleep.
Change Your Sleeping Position: In the second and especially the third trimester, avoid sleeping on your back. The safest position is on your side, particularly the left side, which improves blood flow to the placenta. Use pillows to support your back, abdomen, and between your knees for comfort.
Manage Heartburn: Avoid eating large meals or spicy, acidic, or fried foods close to bedtime. Try sleeping with your head and shoulders elevated on pillows.
Address Leg Cramps and RLS: Stay hydrated and try gentle stretching of your calf muscles before bed. If you experience RLS, a warm bath or massaging your legs may provide relief. Talk to your doctor about whether an iron or folate supplement might be helpful.
Limit Fluids Before Bed, But Stay Hydrated During the Day: Drink plenty of water throughout the day, but try to reduce your intake in the 1-2 hours before you go to sleep to minimize nighttime trips to the bathroom.
Get Some Gentle Exercise: Regular physical activity, like walking or swimming, can improve sleep quality. Avoid strenuous exercise close to bedtime.
If these tips aren't enough, when should you seek further help?
When to Get Professional Help for Sleep Disturbances During Pregnancy
You should speak with your obstetrician or another healthcare provider if your sleep problems are causing significant issues in your daily life. It is important to seek professional help if:
Your sleep difficulties are causing you significant emotional distress, anxiety, or symptoms of depression.
You are so tired during the day that it interferes with your ability to work, care for your family, or function safely.
You have symptoms of a specific sleep disorder, such as the uncontrollable urge to move your legs (RLS), or loud snoring paired with gasping or pauses in breathing (SDB).
You are considering taking any over-the-counter sleep aids, medications, or herbal supplements, as these should always be discussed with a doctor first.
Key Takeaways About Sleep and Sleep Disorders Associated With Pregnancy
Significant sleep disturbance is an expected part of the pregnancy experience for most women, with problems often worsening in the third trimester.
The causes are directly related to pregnancy itself, including massive hormonal changes and the physical strain of a growing uterus.
Specific sleep disorders, especially insomnia, restless legs syndrome, and sleep-disordered breathing, are much more common during pregnancy.
Prioritizing non-medication strategies like sleep hygiene, lifestyle adjustments, and clinical therapies like CBT-I or CPAP are the safest and most effective approach for many sleep issues and sleep disorders.
Poor sleep is more than an inconvenience; it is a modifiable risk factor for serious maternal and fetal health complications.
One of the most important actions you can take is to avoid sleeping on your back in the second half of pregnancy to ensure optimal blood flow to your baby.
Concerned about your sleep? We always advocate talking to your primary care health provider in the first instance.
You can also talk to a NZ sleep clinic like The Better Sleep Clinic for sleep help. Whether it’s an Auckland sleep clinic, Wellington sleep clinic, Christchurch sleep clinic, Hamilton sleep clinic, New Plymouth sleep clinic or anywhere in NZ, we can help. We specialise in the recommended treatments for circadian rhythm disorders such as delayed sleep phase as well as treatments for other sleep disorders such as insomnia treatment - CBT for insomnia.
Book an assessment (no referral required) or, if you have a specific, question enquire about treatment, and get started addressing your sleep problems today.
Frequently Asked Questions About Sleep And The Brain
Q1: Is it normal to have trouble sleeping during pregnancy?
A1: Yes, it is very normal to have trouble sleeping during pregnancy. Research shows that the vast majority of women—between 66% and 97%—experience significant changes to their sleep, and these issues often become more intense as the pregnancy progresses into the third trimester (Christian et al., 2019; Facco et al., 2010).
Q2: What causes poor sleep during pregnancy?
A2: Poor sleep during pregnancy is caused by a combination of profound physical and hormonal changes. Rising levels of hormones like progesterone and estrogen can cause daytime sleepiness, nasal congestion, and relaxation of muscles that lead to heartburn and frequent urination (Cunningham et al., 2018). At the same time, physical changes like the growth of the uterus, weight gain, and fluid retention contribute to back pain, leg cramps, and difficulty finding a comfortable sleeping position.
Q3: Can sleep problems during pregnancy harm my baby?
A3: While occasional nights of poor sleep are not a cause for alarm, chronic sleep deprivation or untreated sleep disorders can pose risks. Studies have linked poor maternal sleep to adverse outcomes, including an increased risk for preterm birth (Micheli et al., 2011), and having a baby that is small for gestational age (SGA), meaning they weigh less than expected (Abeysena et al., 2009; Wang et al., 2017).
Q4: What is the safest sleep position during late pregnancy?
A4: The safest sleeping position during the second and third trimesters is on your side. Research has shown that going to sleep on your back (the supine position) is associated with a 2.6-fold increased risk of late-term stillbirth (Cronin et al., 2019). This is because the weight of the uterus can compress major blood vessels, reducing blood flow to the baby.
Q5: Why do I have an uncontrollable urge to move my legs at night now that I'm pregnant?
A5: You may be experiencing Restless Legs Syndrome (RLS), a condition that is two to three times more common in pregnant women than in the general population (Manconi et al., 2012). The uncomfortable urge to move your legs, especially in the evening and at night, is often linked to iron and folate deficiencies or hormonal changes during pregnancy. For most women, these symptoms resolve on their own shortly after delivery.
Q6: Is snoring during pregnancy a cause for concern?
A6: You should mention it to your doctor. While snoring is common, a new onset of loud, habitual snoring can be a sign of sleep-disordered breathing (SDB), a condition where breathing repeatedly stops and starts during sleep. SDB is a concern because it is linked to a higher risk of developing serious pregnancy complications, including gestational hypertension and preeclampsia (Facco et al., 2017).
Q7: What can I do to sleep better during pregnancy without medication?
A7: There are several effective, non-medication strategies. For insomnia, Cognitive Behavioral Therapy for Insomnia (CBT-I) is a highly effective and recommended treatment during pregnancy (Manber et al., 2019). Other helpful tips include discussing loud snoring with your family doctor, and using pillows to support your body while sleeping on your side.
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Written By The Better Sleep Clinic
Reviewed By Dan Ford, Sleep Psychologist
