Obstructive sleep apnoea and hypertensive disorders of pregnancy: Causality, continuous positive airway pressure and haemodynamics
Ernawati Darmawan, Wiku Andonotopo, Efendi Lukas, Mochammad Besari Adi Pramono, Julian Dewantiningrum, Wisnu Prabowo, Muhammad Adrianes Bachnas, I. Nyoman Hariyasa Sanjaya, Anak Agung Gede Putra Wiradnyana, Anak Agung Ngurah Jaya Kusuma, Khanisyah Erza Gumilar, Muhammad Ilham Aldika Akbar, Dudy Aldiansyah, Aloysius Suryawan, Ridwan Abdullah Putra, Anita Deborah Anwar, Laksmana Adi Krista Nugraha, Waskita Ekamaheswara Kasumba Andanaputra, Wibisana Andika Krista Dharma, Milan StanojevicAbstract:
Obstructive sleep apnoea (OSA) has emerged as a critical but underrecognised driver of hypertensive disorders of pregnancy (HDP). This review systematically examines the causal pathways, therapeutic potential of continuous positive airway pressure (CPAP) and maternal–placental haemodynamics that link OSA with adverse pregnancy outcomes. Comprehensive searches of PubMed, Scopus and Web of Science up to October 2025 identified 1198 records; 43 studies met the inclusion criteria following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Data were extracted independently and assessed for risk of bias using A Measurement Tool to Assess Systematic Reviews, version 2, Risk of Bias in Non-randomised Studies of Interventions, Risk of Bias 2 Tool for Randomised Trials, Newcastle–Ottawa Scale or SANRA tools as appropriate. The synthesis integrates epidemiologic, physiologic and interventional evidence across 20 core studies supported by quantitative meta-analyses and mechanistic investigations. OSA was consistently associated with higher risks of gestational hypertension, preeclampsia and placental ischaemic disease through recurrent hypoxia, endothelial dysfunction and angiogenic imbalance. Haemodynamic data revealed loss of nocturnal blood pressure dipping, elevated systemic vascular resistance and impaired uteroplacental perfusion. CPAP therapy improved mean arterial pressure, cardiac output stability and fetal Doppler indices without adverse perinatal effects. The findings support OSA as a modifiable vascular stressor in pregnancy and position CPAP as a plausible interventional strategy. Integrating OSA screening into antenatal care, alongside haemodynamic monitoring, offers a practical route to reducing hypertensive and metabolic complications. The review underscores the need for multicenter randomised trials, standardised diagnostic criteria and policies ensuring equitable CPAP access to improve maternal and neonatal outcomes worldwide.