Obstructive sleep apnea in pregnancy: key updates from 2026 CHEST guidelines

Obstetrics & Gynaecology

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterised by recurrent episodes of partial or complete upper airway obstruction during sleep, resulting in intermittent hypoxemia, sleep fragmentation and excessive daytime sleepiness.[1] Pregnancy-related physiological changes, including weight gain, hormonal fluctuations, upper airway oedema and altered respiratory mechanics, may increase susceptibility to OSA or aggravate pre-existing disease. Untreated OSA during pregnancy has been associated with adverse maternal and fetal outcomes, including hypertensive disorders, gestational diabetes and pregnancy complications.The 2026 American College of Chest Physicians (CHEST) clinical practice guideline provides recommendations for screening, diagnosis and management of OSA during pregnancy. Emphasis has been placed on identifying at-risk pregnant individuals, selecting appropriate diagnostic approaches, initiating positive airway pressure (PAP) therapy and reassessing OSA following delivery. These recommendations aim to support timely intervention while accounting for the physiological and clinical considerations associated with pregnancy.Screening for OSA during pregnancyScreening for OSA has been suggested in pregnant individuals to facilitate early identification and appropriate management. Clinical suspicion should be heightened in those presenting with habitual snoring, witnessed apneic episodes, excessive daytime sleepiness or other features suggestive of sleep-disordered breathingFor pregnant individuals undergoing screening, either a pregnancy-specific screening instrument or a standard OSA screening tool has been suggested. The choice of instrument may be guided by clinical availability and the characteristics of the population being assessedPregnancy-specific tools may be useful because conventional screening instruments may not adequately account for physiological changes occurring during gestation. However, standard screening tools can also be used to identify individuals who may require further diagnostic evaluationDiagnostic evaluation of OSAFollowing a positive screening assessment or the identification of clinical features suggestive of OSA, diagnostic testing is recommended to establish the presence and severity of the disorder. The CHEST guideline suggests that either home-based diagnostic devices or laboratory-based sleep studies may be used in pregnant individuals undergoing evaluation for OSA.Home-based diagnostic testing: Portable sleep diagnostic devices may be used to assess respiratory events and oxygen desaturation during sleep. These devices offer the advantage of convenience and may improve accessibility to diagnostic evaluationLaboratory-based testing: Polysomnography conducted in a sleep laboratory provides a comprehensive assessment of sleep architecture, respiratory events, oxygen saturation and associated physiological changes. It may be particularly useful when additional sleep-related disorders are suspected or when home-based testing is inconclusiveThe selection of a diagnostic approach should be guided by clinical presentation, availability and the need for comprehensive assessment.Treatment thresholds and indications for PAP therapyTreatment decisions are guided by the severity of OSA, symptom burden, associated clinical complications and additional risk factors. The guideline recommends that treatment be considered according to the apnea-hypopnea index (AHI), which represents the number of apneas and hypopneas recorded per hour of sleepFor pregnant individuals diagnosed with OSA during pregnancy, treatment has been suggested when an AHI of 5-15 events/hour is accompanied by symptoms, clinical sequelae, comorbidities or additional risk factors. These may include hypertension, diabetes and a history of strokeIn contrast, PAP therapy is recommended for individuals with an AHI exceeding 15 events/hour, irrespective of the presence of symptoms or comorbidities. This approach emphasises the importance of treating more severe OSA even when overt clinical manifestations are absentSelection of PAP therapyFor pregnant individuals diagnosed with OSA for whom treatment is indicated, the use of any form of PAP therapy has been suggested over no treatment. Furthermore, PAP therapy has been preferred over alternative treatment approaches in this populationPAP therapy maintains upper airway patency by delivering pressurised air through a mask during sleep, thereby reducing obstructive respiratory events. Treatment may help improve nocturnal oxygenation and sleep continuity while addressing the underlying airway obstructionFor pregnant individuals who were receiving continuous positive airway pressure (CPAP) therapy for OSA before pregnancy, the use of auto-adjusting positive airway pressure (APAP) has been suggested over the continuation of fixed-pressure CPAP. APAP automatically adjusts delivered airway pressure in response to variations in airflow and respiratory obstruction. This approach may accommodate changes in pressure requirements occurring throughout pregnancyManagement of residual daytime sleepinessDespite adequate PAP treatment, residual excessive daytime sleepiness may persist in some pregnant individuals with OSA. To address this concern, scheduled naps have been suggested whenever feasibleThe use of stimulant medications has been suggested only on an as-needed basis when scheduled naps have failed to provide adequate relief. This approach prioritises nonpharmacological management and limits unnecessary stimulant exposure during pregnancyPostpartum reassessment of OSAPregnancy-related physiological changes may influence the severity and clinical presentation of OSA. Therefore, reassessment following delivery has been suggested in individuals who were previously diagnosed with OSA during pregnancyPostpartum evaluation is important for determining whether OSA persists and whether continued treatment is required. The need for ongoing PAP therapy should be reviewed according to the reassessment findings and individual clinical statusConclusionThe CHEST clinical practice guideline highlights the importance of systematic screening, timely diagnosis and appropriate management of OSA during pregnancy. Pregnancy-specific or standard screening tools, together with home-based or laboratory-based diagnostic testing, can facilitate disease identification. Treatment decisions should be guided by AHI severity, associated symptoms and additional maternal risk factors. PAP therapy remains the preferred treatment when indicated, with APAP suggested for individuals receiving CPAP before pregnancy. Scheduled naps are prioritised for managing residual sleepiness, while postpartum reassessment is recommended to determine the persistence of OSA. These recommendations support individualised management and continuity of care throughout pregnancy and after delivery.[2]Reference(s):1. Abbasi A, Gupta SS, Sabharwal N, et al. A comprehensive review of obstructive sleep apnea. Sleep Sci. 2021;14(2):142-154. doi:10.5935/1984-0063.20200056. https://pmc.ncbi.nlm.nih.gov/articles/PMC8340897/2. D'Ambrosio CM, Dust C, Dominguez JE, et al. OSA in Pregnancy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2026;170(4):1284-1298. doi:10.1016/j.chest.2026.06.058. https://journal.chestnet.org/article/S0012-3692(26)06181-7/fulltext