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INTRODUCTION: 1.1.                                          OVERVIEW: Sleepdisturbance and tiredness are the most frequent and persistent complaintsreported from pregnant personnel. Estimated 60% ofconceived women in the last three months report of tiredness, and above 75%complained of abnormal sleep, decreased vigilance, and  need to nap through the workinghours. During pregnancy sleep abnormality and fatigue leads to prolongedlabour and c section delivery. These complications may affect both themother and the infant both in short and wide term.

1 Sleep abnormality, a commonproblem in conceived period, can occur from myriad, hormonal, systemic, andmetabolic changes. Sleepdisturbances, a common complaint in pregnancy, can result from myriadphysiological, hormonal, vascular, and metabolic changes. In amodern research from the National Sleep Foundation, over 78% of women reportedabout their sleep was different during conceived period than any other time;however, there was no improvement in this aspect of sleep the women weredescribing.

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 Empirical studies suggest that upto 25% of pregnant women report significant sleep abnormality in the firstthree months, with rates climbing to approximately 76% by the last three months.It is  accepted that sleep worsens withthe time in gestational time, our current knowledge depends heavily on a smallhandful of reports with one or two assessments and a broad range ofmeasurements.2 Studies showed a gradual Restlessleg syndrome risk increase with the number of pregnancies. However, this tendsto settle during the post-partum period.

7 as  sleep disorder, with significantly reduced sleeptime in the last three months, 5 there is risk of impaired function during theday, and risk of unfavourable influences on the duration and mode of deliverywith increased likelihood of operative delivery.3 Postpartum depression is anincreasingly recognized public health problem with far-reaching consequencesfor both infants and mothers. Changes in sleep during pregnancy have beenhypothesized as a modifiable risk factor for the development of postpartumdepression. Poor sleep may serve as not only a marker of impending depressionbut also as a contributing cause.4 GAP:Pakistanipregnant women are mostly housewives and have to do a lot of household workeven in pregnancy which can lead to sleep disturbance. This issue is not beingaddressed in Pakistan and there is very little data available on sleepdisorders in Pakistani pregnant women. 1.

2.                                          OBJECTIVE:The aim of this study is toidentify sleep disturbance in pregnant women of Lahore 1.3.                                          RATIONALE:This study will help to educatepregnant women that sleep disturbance in pregnancy can lead to variousdisorders, as it is an issue not being addressed in our society the knowledgeof sleep disturbance in pregnant women will initiate awareness programs forpregnant women to resolve this issue. 1.4.                                          OPERATIONAL DEFINITION Pittsburgh sleep quality index (PSQI):  is a reliable self-rated questionnaire thatevaluates sleep quality.

The PSQI comprises of seven components including;sleep parameters, latency, duration, efficacy, bedtime problems, consumption ofsleep medication and hindrance in daily function, each assesses a specificclinical feature of sleep habits over a one-month period. The points for eachelement range from 0 to 3, 3 being the highest while 0 the lowest, these scoresfrom each component are added into the total score, also known as the globalscore ranging from 0-21 the highest indicating the worst sleep and scoregreater 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 tobe 0.

736 by Md. Dilshad Manzar et al.6                         2.

     LITERATURE REVIEW Mindellet, al. 2015 This was a prospective, cohortstudy of healthy nulliparous women, recruited between 6 and 20 weeks ofgestation, who completed a baseline sleep survey at enrollment with follow-upin the third trimester. The survey was composed of the following validatedsleep questionnaires: The study concluded that Sleep disturbances are prevalentamong healthy nulliparous women and increase significantly during pregnancy.

7 Naghi, I., et al., 2011 Inthis study, the relationship between sleep quality and type and duration oflabour has been evaluated. A total of 88 pregnant women completed thePittsburgh Sleep Questionnaire three times during their last 3 weeks ofpregnancy at their prenatal visits and once postpartum it was found that womenwith sleep problems experience longer labour duration and are more likely toundergo a caesarean section.8 Zafarghandi,N., et al.,2012 The aim of this study was toassess 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 Sleepduration and quality of sleep can affect the type of delivery, length of laborstages, as well as neonates’ Apgar score and birth weight. Such predictors oflabor and fetal outcome should be assessed during prenatal evaluations.9 Faisal-Cury, A., et al., 2009 The aim of this study was toexamine the relationship between sleep disturbance in pregnancy and persistentCMD among low-income pregnant women living in Brazil. This was a prospectivecohort study conducted with pregnant women recruited from public primary careclinics in São Paulo, Brazil. In this sample of low-income pregnant womenliving in Brazil, the presence of sleep disturbance during pregnancy wasassociated with persistent common mental disorder in the postpartum period.

Identification of sleep disturbance in pregnant women with CMD will beimportant in order to recognize those women at higher risk of persistent CMD inthe postpartum period10 Delia,H. G., & James, J. (2016). Duringpregnancy, women typically see a disruption in sleep and an abnormal amount ofabdominal fat accumulation. The purpose of thisstudy is to determine if there is a relationship between sleep disturbance,quality or quantity and the accumulation of abdominal fat during pregnancy.

Theconclusion of the study was there isa negative relationship between sleep disturbance and the accumulation of abdominalfat (IAAT) independent of the influence of overall adiposity. These resultsindicate that low sleep disturbance is strongly associated with lower abdominalfat during pregnancy.11 Okun, M.L., 2009 thisstudy proposed a model linking sleep disturbances in early gestation to adversepregnancy outcomes via increased inflammation.

Specifically, proposed a feedforward loop between sleep disruption and inflammation during a critical periodof early pregnancy when inflammation can act to inhibit the trophoblastinvasion and associated remodelling of maternal blood vessels that perfuse theplacenta. Assessing sleep disturbances as a risk factor for adverse outcomescould provide a target for intervention especially since sleep problems areamenable to treatment.12Micheli, K., et al.,2011 The findings of this study suggest that womenwith severe snoring in late pregnancy have a higher risk forfetal-growth-restricted neonates; and women with sleep deprivation have ahigher risk for preterm births.

The mechanisms underlying these associationsremain unclear.13  3.    MATERIALAND METHODS 3.1.           STUDYDESIGN:ACross sectional Survey 3.2.           SETTING:Datawill be collected from Gynaecological wards of Government and Private Hospitalsof Lahore 3.

3.           DURATION:Studywill be completed in 3 months after the approval of synopsis 3.4.            SAMPLING TECHNIQUE:3.5.           SAMPLE SIZE/COLLECTION:  X ? Z (C/100)2 r (100-r) n ? N x/((N-1)E2 + x) E ? Sqrt(N – n) x/n (N-1) Inthis formula:N?Population sizen? SamplesizeE? Marginof errorr?Fraction of responseZ(c?100) ? critical value for the confidence levelc.Thevalues which put in this formula are:·        Error Eis = 5%·        Levelof confidence c is = 90%·        Populationsize is = 20,000·        Andthe response rate is = 85% 3.6.


     InclusionCriteria:Pregnant women with gestation age less than 37 weeks will be included3.6.2.     ExclusionCriteria:PregnantWomen with hypertension, diabetes mellitus, or those who needed emergencycesarean section will be excluded 3.7.           DATACOLLECTION PROCEDURE:It is a cross sectional study.

The data will be collectedfrom the pregnant women of Lahore from government and private hospitals. Dataof women who completely fulfil the inclusion criteria will be included in thestudy. An informed consent will be taken, and the purpose of the study will beclarified in detail to the women.     3.8.

           DATACOLLECTION TOOLS:PSQIis a questionnaire with self-rating which will be adopted to assess the sleepdisorders of pregnant women. 3.9.           ETHICAL CONSIDERATION:Datawill be collected from pregnant women of Lahore only after an informed consentand the safety of the collected data will be ensured. The ethical committee ofAzra Naheed Medical College will approve the execution of this study inHospitals and Gynaecological wards. Data collection will not affect theparticipant’s ethical values and the researcher will also abide by professionalmorality. 3.

10.       STATISTICALANALYSIS: Allcollected data will be entered via computer software SPSS version 21 which iswhere it will also be calculated. For categorical variables frequency andpercentage will be used and for discrete variables mean and standard deviationwill be used.                      REFERENCES:  1.         Tsai,S.

-Y., et al., Daily Sleep and FatigueCharacteristics 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 isAssociated with Preterm Birth. Sleep, 2011. 34(11): p. 1493-1498.3.

         Balendran, J., etal., A common sleep disorder inpregnancy: Restless legs syndrome and its predictors. Australian and NewZealand Journal of Obstetrics and Gynaecology, 2011. 51(3): p.

262-264.4.         Park, E.M., S.Meltzer-Brody, and R.

Stickgold, Poorsleep maintenance and subjective sleep quality are associated with postpartummaternal depression symptom severity. Arch Womens Ment Health, 2013. 16(6): p. 539-47.5.         Farrahi Moghaddam,J., et al., Reliability and validity ofthe Persian version of the Pittsburgh Sleep Quality Index (PSQI-P).

SleepBreath, 2012. 16(1): p. 79-82.6.         Manzar, M.

D., etal., Validity of the Pittsburgh SleepQuality 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 patternsand sleep disturbances across pregnancy. Sleep medicine, 2015. 16(4): p. 483-488.

8.         Naghi, I., et al., Sleep disturbance in late pregnancy and typeand duration of labour.

Journal of Obstetrics and Gynaecology, 2011. 31(6): p. 489-491.9.         Zafarghandi, N.

, etal., The effects of sleep quality andduration in late pregnancy on labor and fetal outcome. The Journal ofMaternal-Fetal & Neonatal Medicine, 2012. 25(5): p. 535-537.

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

11.       Delia,H.G.

and J. James, Sleep Quality, But NotQuantity, is Associated with Reduced Abdominal Fat Accumulation DuringPregnancy. 2016.12.       Okun,M.

L., How Disturbed Sleep May Be a RiskFactor for Adverse Pregnancy Outcomes A Hypothesis. 2009. 64(4): p.

273-80.13.       Micheli,K., et al.

, Sleep patterns in latepregnancy and risk of preterm birth and fetal growth restriction.Epidemiology, 2011. 22(5): p.738-744.

       4.     APPENDICIES 4.1.                    APPENDIX1CONSENTFORMRespectedparticipant, the study you are going to participate is”Sleepdisturbance in pregnant women of Lahore” Pleasegive approval of your participation by filling the following form.·        I confirm that I haveread and understand the information for the study.·        I understand thattaking part in voluntary that I am free to withdraw any time, without givingany reason.·        I agree to take part inthis study and researcher having the following personal detail for the purposeof contacting me directly to arrange a research interview Name:              _____________________________________________Gender:           ____________Age: ______________ Date: _________Phone No:       _____________________________________________Address:          _____________________________________________Signature:        ______________________________________________        4.2.

                    APPENDIX 2QUESTIONNAIRE DEMOGRAPHICS: Name____________________________Date__________________SleepQuality Assessment (PSQI) Whatis PSQI, and what is it measuring?  The Pittsburgh Sleep Quality Index (PSQI) is aneffective instrument used to measure the quality and patterns of sleep inadults.  It differentiates “poor” from”good” sleep quality by measuring seven areas (components): subjective sleepquality, sleep latency, sleep duration, habitual sleep efficiency, sleepdisturbances, use of sleeping medications, and daytime dysfunction over thelast month.   INSTRUCTIONS: The following questions relate to your usual sleephabits during the past month only.  Youranswers should indicate the most        accurate reply for the majority of days and nights in the pastmonth.  Please answer all questions. During thepast month,  1.      Whenhave you usually gone to bed?                          ____________________________________ 2.

      Howlong (in minutes) has it taken you to fall asleep each night?  ____________________________________ 3.      Whattime 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) Less than once a week (1) Once or twice a week (2) Three or more times a week (3)     A.

  Cannot get to sleep within 30 minutes             B.  Wake up in the middle of the night or early morning             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             I.  Have pain              J.  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 done?         9.  During the past month, how would you rate your sleep quality overall?   Very good (0) Fairly good (1) Fairly bad (2) Very bad (3)          B. How many hours were you in bed?                                                               ____________________________________              Scoring   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__________________      

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