Table 3.

Summary of available data on insomnia during peripartum

Insomnia evaluation during peripartum

• Clinical interview may evaluate nocturnal/daytime symptoms, daytime lifestyle that may interfere with sleep,comorbid conditions including Sleep Disorder Breathing and Restless Leg Syndrome, psychiatric disorders or medical conditions • Specific rating scales may be useful. Insomnia Severity Index (ISI) was the most used rating scale, Consensus Sleep Diary (CSD), Epworth Sleepiness Scale (ESS) may be useful for evaluating nocturnal/daytime symptoms

Insomnia treatment during peripartum

• Cognitive behavioral therapy for insomnia (CBT-I) is the preferred choice in insomnia patients, it is suggested for insomnia during peripartum too • CBT-I adaptations for pre- and postpartum periods have been proposed and may include: -Sleep psychoeducation which may be adapted to pregnancy-related issues, -Sleep restriction may be modified to reduce excessive related increase of fatigue and stress with flexibility in bed/wake-times -Strategies targeting emotional aspects may plasy a more central role compared to standard CBT-I protocols -Family issues may be taken into consideration -Sleep psychoeducation about sleep patterns in infants and newborns may be included in CBT-I treatment suring the post-partum -Flexibility in bed/wake-times may be used with bed- and wake-time windows (30–60 min) to accommodate variable infant sleep patterns in post partum Digital CBT-I administration have been proven to be as well as effective than in person CBT-I administration for insomnia during peripartum • CBT-I has been shown to be useful in improving insomnia, mood anxiety symptoms and fatigue during peripartum • Pharmacological treatment for insomnia during peripartum are suggested to be considered in particular conditions such as in women who do not respond to non-pharmacologic therapy, who may present severe forms of insomnia with anxiety and mood issues, when there are no alternatives and the benefit outweighs the risk • Pharmacological treatment for insomnia during peripartum are suggested to follow shared decision making approach • Among benzodiazepines and benzodiazepine-related drugs the benzodiazepine lorazepam is the compound with largest available data • Lorazepam is suggested to be used with caution at the lowest effective dosage for the shortest possible duration. Benzodiazepines benzodiazepine-related drugs have been related to a range of adverse birth outcomes, maternal use during the third trimester has been associated with floppy infant syndrome and withdrawal symptoms which may persist for several months in the neonate. Teratogenic risks have not been confirmed but cautions should be used during the first trimester • Most other sedative-hypnotics including zolpidem hold limited available data during peripartum • Among antidepressants, doxepin hold limited available data while trazodone has been used in at least 3 studies involving humans during peripartum • No data are available for exogenous melatonin, melatonin receptor agonists and orexin receptor antagonists • Since antihistamines are not recommended for insomnia treatment and few human data are available for the treatment of insomnia during peripartum, their use may be not used for insomnia treatment during peripartum