INTRODUCTION: a common complaint in pregnancy, can result from





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disturbance and fatigue are among the most frequent and persistent complaints
reported by pregnant women. Approximately 60%
of pregnant women during the last trimester report being fatigued, and more
than 75% complained of disturbed sleep, decreased vigilance, and a need to nap
during the day. Prenatal sleep disturbance and fatigue have separately
predicted prolonged labour and caesarean delivery. These complications may
affect both the mother and the infant both in short and long term.1


Sleep disturbances, a common
complaint in pregnancy, can result from myriad physiological, hormonal,
vascular, and metabolic changes. Sleep disturbances, a common complaint in pregnancy,
can result from myriad physiological, hormonal, vascular, and metabolic
changes. In a recent poll from the National Sleep Foundation, over
79% of women reported that their sleep was different during pregnancy than at
any other time; however, no distinction was made as to which aspect of sleep
the women were describing.


Empirical studies suggest that up
to 25% of pregnant women report significant sleep disturbance in the first
trimester, with rates climbing to nearly 75% by the third trimester. While it
is accepted that sleep progressively worsens across the gestational period, our
current knowledge relies heavily on a small handful of reports with one or two
assessments and a broad range of measurements.2


Studies showed a gradual Restless
leg syndrome risk increase with the number of pregnancies. However, this tends
to settle during the post-partum period.7 as a sleep disorder, with
significantly reduced sleep time in the third trimester, 5 there is risk of
impaired function during the day, and risk of unfavourable influences on the
duration and mode of delivery with increased likelihood of operative delivery.3


Postpartum depression is an
increasingly recognized public health problem with far-reaching consequences
for both infants and mothers. Changes in sleep during pregnancy have been
hypothesized as a modifiable risk factor for the development of postpartum depression.
Poor sleep may serve as not only a marker of impending depression but also as a
contributing cause.4



pregnant women are mostly housewives and have to do a lot of household work
even in pregnancy which can lead to sleep disturbance. This issue is not being
addressed in Pakistan and there is very little data available on sleep
disorders in Pakistani pregnant women.



The aim of this study is to
identify sleep disturbance in pregnant women of Lahore



This study will help to educate
pregnant women that sleep disturbance in pregnancy can lead to various
disorders, as it is an issue not being addressed in our society the knowledge
of sleep disturbance in pregnant women will initiate awareness programs for
pregnant women to resolve this issue.




Pittsburgh sleep quality index (PSQI):  is a reliable self-rated questionnaire that
evaluates sleep quality. The PSQI comprises of seven components including;
sleep parameters, latency, duration, efficacy, bedtime problems, consumption of
sleep medication and hindrance in daily function, each assesses a specific
clinical feature of sleep habits over a one-month period. The points for each
element range from 0 to 3, 3 being the highest while 0 the lowest, these scores
from each component are added into the total score, also known as the global
score ranging from 0-21 the highest indicating the worst sleep and score
greater than or equal to 5 point out poor sleeping qualities.

PSQI holds a validity of 94% and reliability of 72%.5  and the value of Cronbach’s alpha is found to
be 0.736 by Md. Dilshad Manzar et al.6




























et, al. 2015 This was a prospective, cohort
study of healthy nulliparous women, recruited between 6 and 20 weeks of
gestation, who completed a baseline sleep survey at enrollment with follow-up
in the third trimester. The survey was composed of the following validated
sleep questionnaires: The study concluded that Sleep disturbances are prevalent
among healthy nulliparous women and increase significantly during pregnancy.7


Naghi, I., et al., 2011 In
this study, the relationship between sleep quality and type and duration of
labour has been evaluated. A total of 88 pregnant women completed the
Pittsburgh Sleep Questionnaire three times during their last 3 weeks of
pregnancy at their prenatal visits and once postpartum it was found that women
with sleep problems experience longer labour duration and are more likely to
undergo a caesarean section.8


N., et al.,2012 The aim of this study was to
assess the effects of sleep duration and its quality on labor and fetal outcome.
In a cross sectional study, primigravida women with singleton pregnancy
(gestational age > 37 weeks) were recruited. The study concluded that Sleep
duration and quality of sleep can affect the type of delivery, length of labor
stages, as well as neonates’ Apgar score and birth weight. Such predictors of
labor and fetal outcome should be assessed during prenatal evaluations.9


Faisal-Cury, A., et al., 2009 The aim of this study was to
examine the relationship between sleep disturbance in pregnancy and persistent
CMD among low-income pregnant women living in Brazil. This was a prospective
cohort study conducted with pregnant women recruited from public primary care
clinics in São Paulo, Brazil. In this sample of low-income pregnant women
living in Brazil, the presence of sleep disturbance during pregnancy was
associated with persistent common mental disorder in the postpartum period.
Identification of sleep disturbance in pregnant women with CMD will be
important in order to recognize those women at higher risk of persistent CMD in
the postpartum period10


H. G., & James, J. (2016). During
pregnancy, women typically see a disruption in sleep and an abnormal amount of
abdominal fat accumulation. The purpose of this study
is to determine if there is a relationship between sleep disturbance, quality
or quantity and the accumulation of abdominal fat during pregnancy. The
conclusion of the study was there is
a negative relationship between sleep disturbance and the accumulation of
abdominal fat (IAAT) independent of the influence of overall adiposity. These
results indicate that low sleep disturbance is strongly associated with lower
abdominal fat during pregnancy.11


Okun, M.L., 2009 this
study proposed a model linking sleep disturbances in early gestation to adverse
pregnancy outcomes via increased inflammation. Specifically, proposed a feed
forward loop between sleep disruption and inflammation during a critical period
of early pregnancy when inflammation can act to inhibit the trophoblast
invasion and associated remodelling of maternal blood vessels that perfuse the
placenta. Assessing sleep disturbances as a risk factor for adverse outcomes
could provide a target for intervention especially since sleep problems are
amenable to treatment.12

Micheli, K., et al.,
2011 The findings of this study suggest that women
with severe snoring in late pregnancy have a higher risk for
fetal-growth-restricted neonates; and women with sleep deprivation have a
higher risk for preterm births. The mechanisms underlying these associations
remain unclear.13






Cross sectional Survey



will be collected from Gynaecological wards of Government and Private Hospitals
of Lahore



will be completed in 3 months after the approval of synopsis







Z (C/100)2 r



N x/((N-1)E2 + x)



Sqrt(N – n) x/n (N-1)

this formula:

Population size

n? Sample

E? Margin
of error

Fraction of response

Z (c?100)
? critical value for the confidence level

values which put in this formula are:

Error E
is = 5%

of confidence c is = 90%

size is = 20,000

the response rate is = 85%




Pregnant women with gestation age less than 37 weeks will be included


Women with hypertension, diabetes mellitus, or those who needed emergency
cesarean section will be excluded



It is a cross sectional study. The data will be collected
from the pregnant women of Lahore from government and private hospitals. Data
of women who completely fulfil the inclusion criteria will be included in the
study. An informed consent will be taken, and the purpose of the study will be
clarified in detail to the women.    


is a questionnaire with self-rating which will be adopted to assess the sleep
disorders of pregnant women.



will be collected from pregnant women of Lahore only after an informed consent
and the safety of the collected data will be ensured. The ethical committee of
Azra Naheed Medical College will approve the execution of this study in
Hospitals and Gynaecological wards. Data collection will not affect the
participant’s ethical values and the researcher will also abide by professional




collected data will be entered via computer software SPSS version 21 which is
where it will also be calculated. For categorical variables frequency and
percentage will be used and for discrete variables mean and standard deviation
will be used.


























1.         Tsai,
S.-Y., et al., Daily Sleep and Fatigue
Characteristics in Nulliparous Women during the Third Trimester of Pregnancy.
Sleep, 2012. 35(2): p. 257-262.

2.         Okun, M.L., C.D. Schetter,
and L.M. Glynn, Poor Sleep Quality is
Associated with Preterm Birth. Sleep, 2011. 34(11): p. 1493-1498.

3.         Balendran, J., et
al., A common sleep disorder in
pregnancy: Restless legs syndrome and its predictors. Australian and New
Zealand Journal of Obstetrics and Gynaecology, 2011. 51(3): p. 262-264.

4.         Park, E.M., S.
Meltzer-Brody, and R. Stickgold, Poor
sleep maintenance and subjective sleep quality are associated with postpartum
maternal depression symptom severity. Arch Womens Ment Health, 2013. 16(6): p. 539-47.

5.         Farrahi Moghaddam,
J., et al., Reliability and validity of
the Persian version of the Pittsburgh Sleep Quality Index (PSQI-P). Sleep
Breath, 2012. 16(1): p. 79-82.

6.         Manzar, M.D., et
al., Validity of the Pittsburgh Sleep
Quality Index in Indian University Students. Oman Med J, 2015. 30(3): p. 193-202.

7.         Mindell, J.A., R.A.
Cook, and J. Nikolovski, Sleep patterns
and sleep disturbances across pregnancy. Sleep medicine, 2015. 16(4): p. 483-488.

8.         Naghi, I., et al., Sleep disturbance in late pregnancy and type
and duration of labour. Journal of Obstetrics and Gynaecology, 2011. 31(6): p. 489-491.

9.         Zafarghandi, N., et
al., The effects of sleep quality and
duration in late pregnancy on labor and fetal outcome. The Journal of
Maternal-Fetal & Neonatal Medicine, 2012. 25(5): p. 535-537.

10.       Faisal-Cury,
A., et al., Common mental disorders
during pregnancy: prevalence and associated factors among low-income women in
São Paulo, Brazil. Archives of women’s mental health, 2009. 12(5): p. 335.

11.       Delia,
H.G. and J. James, Sleep Quality, But Not
Quantity, is Associated with Reduced Abdominal Fat Accumulation During
Pregnancy. 2016.

12.       Okun,
M.L., How Disturbed Sleep May Be a Risk
Factor for Adverse Pregnancy Outcomes A Hypothesis. 2009. 64(4): p. 273-80.

13.       Micheli,
K., et al., Sleep patterns in late
pregnancy and risk of preterm birth and fetal growth restriction.
Epidemiology, 2011. 22(5): p.












participant, the study you are going to participate is
disturbance in pregnant women of Lahore” Please
give approval of your participation by filling the following form.

I confirm that I have
read and understand the information for the study.

I understand that
taking part in voluntary that I am free to withdraw any time, without giving
any reason.

I agree to take part in
this study and researcher having the following personal detail for the purpose
of contacting me directly to arrange a research interview


Name:              _____________________________________________

Gender:           ____________Age: ______________ Date: _________

Phone No:       _____________________________________________

Address:          _____________________________________________

Signature:        ______________________________________________















Quality Assessment (PSQI)

is PSQI, and what is it measuring? 

The Pittsburgh Sleep Quality Index (PSQI) is an
effective instrument used to measure the quality and patterns of sleep in
adults.  It differentiates “poor” from
“good” sleep quality by measuring seven areas (components): subjective sleep
quality, sleep latency, sleep duration, habitual sleep efficiency, sleep
disturbances, use of sleeping medications, and daytime dysfunction over the
last month.  


The following questions relate to your usual sleep
habits during the past month only.  Your
answers should indicate the most        
accurate reply for the majority of days and nights in the past
month.  Please answer all questions.

During the
past month,


1.      When
have you usually gone to bed?                          ____________________________________

2.      How
long (in minutes) has it taken you to fall asleep each night?  ____________________________________

3.      What
time have you usually gotten up in the morning? 

4.      A.
How many hours of actual sleep did you get at night?      ____________________________________







5.  During the past month, how
often have you had trouble sleeping because you 

Not during the past month (0)

a week

Once or twice a week (2)

or more
a week

    A.  Cannot get to sleep within 30 minutes





    B.  Wake up in the middle of the night or early





    C.  Have to get up to use the bathroom





    D.  Cannot breathe comfortably





    E.  Cough or snore loudly





    F.  Feel too cold





    G. Feel too hot 





    H. Have bad dreams





Have pain 





Other reason (s), please describe, including how often you have had
trouble sleeping  because of this
reason (s):





6.  During the past month, how
often have you taken medicine (prescribed or “over the   counter”) to help you sleep?





7.  During the past month, how
often have you had trouble staying awake while driving, eating meals, or
engaging in social activity?





8.  During the past month, how
much of a problem has it been for you to keep up enthusiasm to get things





9.  During the past month, how
would you rate your sleep quality overall?  




Very bad (3)

How many hours were you in bed?                                                               ____________________________________










Component 1

#9 Score                                                                       



C1 ___________



Component 2

#2 Score (<15min (0), 16-30min (1), 31-60 min (2), >60min (3)) 








+ #5a Score (if sum is
equal 0=0; 1-2=1; 3-4=2; 5-6=3)      




C2 ___________



Component 3

#4 Score (>7(0), 6-7
(1), 5-6 (2), <5 (3)                              C3 ___________     Component 4 (total # of hours asleep) / (total # of hours in bed) x 100                           >85%=0, 75%-84%=!,
65%-74%=2, <65%=3                                C4 ___________     Component 5 # sum of scores 5b to 5j (0=0; 1-9=1; 10-18=2; 19-27=3)           C5 ___________     Component 6 #6 Score                                                                  C6 ___________     Component 7   #7 Score + #8 score (0=0; 1-2=1; 3-4=2; 5-6=3)                C7 ___________       Add the seven component scores together __________________                Global PSQI _______________ A total score of "5" or greater is indicative of poor sleep quality.   If you scored "5" or more it is suggested that you discuss your sleep habits with a healthcare provider 


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