II E L MONUMENTO BAJO EL RÉGIMEN FRANQUISTA
II.1 Aportaciones sobre el origen del monumento (1940- (1940-1969)
II.1.1 El Servicio de Defensa del Patrimonio Artístico Nacional En plena guerra civil, el Gobierno del bando nacional ya había aprobado el decreto por
When considering the direction of any associations observed between unfavourable sleep events and the risk of poor pregnancy outcomes, it was found that, with the exception of three adjusted models, all of the unfavourable sleep events (as described in Tables 3-13 to 3-18) examined in each of the unadjusted and adjusted models increased the risk of all of the poor pregnancy outcomes examined (as described in Table 3-10). In the first of the models that constituted exceptions to this rule, OSA was found to be associated with a lower the risk of PIH (adjusted Log OR= 0.9; CI=0.30 to 2.04; Table 3-13). The second model found that an inverse association between short sleep duration and SGA (adjusted OR=0.90; CI=0.40 to 1.80; Table 3-14). However, both of these models included
covariates that were judged to be mediators in their covariate adjustment sets.
Meanwhile, the third and final model examined the association between sleep duration (as a continuous variable) and hyperglycemia and found an inverse relationship though without considering the possibility that this might have resulted from an imbalanced U-shaped relationship (where an increased odds of hyperglycaemia might have been caused by short or long duration sleep; adjusted OR= 0.2; 0.1 to 0.8; Table 3-14).
In regard to the magnitude of the associations observed between unfavourable sleep events and pregnancy outcomes, it was found that this tended to vary primarily as a result of the following factors:
I. The type of unfavourable sleep events - it being evident that SDB-related sleep characteristics symptoms had the strongest associations with poor pregnancy outcomes, regardless of the poor pregnancy outcomes involved (Table 3-13).
II. The type of pregnancy outcomes – it being evident that late pregnancy maternal events (i.e. GDM, PE and PIH) had the strongest associations with unfavourable sleep characteristics regardless of the specific unfavourable sleep events involved.
III. The categorisation of the unfavourable sleep characteristic used – this was clearly evident when sleep duration was examined as a continuous variable.
Ignoring the possibility of a U-shaped relationship between sleep duration and pregnancy outcomes appeared to reverse the direction of any association between sleep duration and pregnancy outcomes (Table 3-15) IV. The gestational age at which sleep was measured – it being evident sleep measurements recorded earlier or later in pregnancy affected the strength of any association between sleep and pregnancy outcomes, though without affecting the direction of these associations. For instance O'Brien et al.
(2013) reported a far stronger association between snoring which developed (and was measured) during the 3rd trimester and PIH (adjusted OR=2.36; CI=1.48 to 3.77; Table 3-13) compared to snoring that developed prior to the 3rd trimester (adjusted OR= 1.72; CI= 0.80 to 3.71; Table 3-13).
V. The choice of covariates included in the covariate adjustment sets used – it being evident that including covariates likely to operate as mediators within the covariate adjustment sets altered the direction of association between OSA and PIH as well as that between SSD and SGA, whilst only affecting the magnitude of the associations in the remainder of the inappropriately adjusted models.
A detailed summary of the ORs extracted from the studies included in the review, together with lists of the covariates included in these studies covariate adjustment sets are listed in Table 3-13 through to Table 3-18.
Considering the number of pregnancy outcomes examined, it was clear that only 11 separate maternal/perinatal and neonatal outcomes have thus far been examined by studies examining the relationship between sleep and pregnancy outcomes. Furthermore, 3 of these have only been examined by a single study each and few of the remainder have been studied with much consistency in either the definition or categorisation of the variables examined, or in the study designs adopted or the gestational age at which the sleep exposure variables were measured.
At the same time, a total of (only) 8 separate/distinct sleep characteristics have thus far been examined by such studies; and three of these characteristics have only been examined, to-date, by a single study each; whilst for the others there was, once more, little evidence of consistency in the definition, categorisation, measurement tool/point or covariate adjustment sets used.
By far the most attention has been paid to maternal/perinatal characteristics than to neonatal characteristics; and to snoring, OSA and (to a lesser extent) sleep duration. Yet many of the studies failed to present either unadjusted and/or adjusted coefficient estimates (which, together with the lack of consistency in terms of methods, further reduces the scope for meta-analysis). Much of what is known about the relationship between sleep and pregnancy outcomes is therefore based on very little evidence (for most sleep characteristics and most pregnancy outcomes), and appears to be sensitive to difference in sampling, measurement, categorisation and analysis.
Table 3-13 Summary of adjusted and unadjusted ORs of studies that examined the relationship between SDB symptoms and poor pregnancy outcomes.
Study design Reference SDB component Trimester Sample size Unadjusted OR 95% confidante interval Adjusted OR 95% confidante interval
Temporal functional groups (TFG)
Adjusted variables Number of TFGs Number of mediators Number of confounders
Small for gestational age
longitudinal (Bourjeily et al., 2010)
Study design Reference SDB component Trimester Sample size Unadjusted OR 95% confidante interval Adjusted OR 95% confidante interval
Temporal functional groups (TFG)
Adjusted variables Number of TFGs Number of mediators Number of confounders
(Gordon et al.,
longitudinal (Bourjeily et al., 2010)
Study design Reference SDB component Trimester Sample size Unadjusted OR 95% confidante interval Adjusted OR 95% confidante interval
Temporal functional groups (TFG)
Adjusted variables Number of TFGs Number of mediators Number of confounders
Prospective
Case control (Reutrakul et
al., 2013) OSA Late 2nd
longitudinal (Bourjeily et al., 2010)
Snoring 3rd 1000 4.00 2.40 to 6.50 2.30 1.40 to 4.00 1,12, 19, 24, 25,
28, 42 6 1 5
OSA 3rd 1000 1.30 0.60 to 3.20 0.90 0.30 to 2.40 1,12, 19, 24, 25,
28, 42 6 1 5
Study design Reference SDB component Trimester Sample size Unadjusted OR 95% confidante interval Adjusted OR 95% confidante interval
Temporal functional groups (TFG)
Adjusted variables Number of TFGs Number of mediators Number of confounders
Retrospective
Case control (Champagne et
al., 2009) OSA >20
weeks 50 5.60 1.40 to
23.20 7.50 3.50 to 16.20 1, 12, 31, 44 4 0 4
Table 3-14 Summary of adjusted and unadjusted ORs of studies that examined the relationship between sleep duration and poor pregnancy outcomes
Study design Reference Pregnancy outcomes Sleep duration risk group Sample size Trimester Unadjusted OR 95% CI Adjusted OR 95% CI
Functional temporal groups (TFG)
Adjusted variables Number of TFGs Number of mediators Number of confounders
Neonatal outcomes
longitudinal Qiu et al.
(2010)
Study design Reference Pregnancy outcomes Sleep duration risk group Sample size Trimester Unadjusted OR 95% CI Adjusted OR 95% CI
Functional temporal groups (TFG)
Adjusted variables Number of TFGs Number of mediators Number of confounders
Prospective
Table 3-15 Summary of adjusted and unadjusted ORs of studies that examined the relationship between sleep quality and poor pregnancy outcomes.
Study design Reference Pregnancy outcomes Trimester Sample size Unadjusted OR 95% CI Adjusted OR 95% CI Adjustment
Temporal functional group
Number of TFGs Number of mediators Number of confounders
Maternal outcomes
Prospective longitudinal
(Lee and Gay, 2004)
Caesarean
delivery 3rd 131 - - 4.30 1.05 to16.93 12 1 0 1
(Reutrakul et
al., 2011)a Preterm delivery 2nd 169
1.20 1.00 to 1.30 - - Unadjusted 0 0 0
(Okun et al.,
2011) Preterm delivery 3rd 166 1.10 1.03 to 1.18 1.25 1.04 to1.5 9 1 0 1
(Stinson and
Lee, 2003) Preterm delivery 2nd 359 2.36 1.09 to 5.07 - - Unadjusted 0 0 0
(Wang et al., 2017)
GDM and moderately poor
quality
Not
specified 12,506 1.62 1.20 to 2.17 1.19 1.01 to 1.41 1, 2, 5, 14, 15, 17,
19, 31, 38, 42 7 1 6 Neonatal outcomes
Prospective longitudinal
(Howe et al., 2015)
Small for gestational age
3rd
trimester 633 - - 1.00 0.40 to 2.00 1, 2, 8, 17, 27, 28,
31, 41, 45, 48 7 1 6 Small for
gestational age
3rd
trimester 633 - - 1.10 0.50 to 2.70 1, 2, 8, 17, 27, 28,
31, 41, 45, 48 7 1 6
Table 3-16 Summary of adjusted and unadjusted ORs of studies that examined the relationship between sleep disturbance, latency and poor pregnancy outcomes.
Study design Reference Pregnancy outcomes and sleep Trimester Sample size Unadjusted OR 95% CI Adjusted OR 95% CI
Temporal functional group (TFG)
Adjusted variables Number of TFGs Number of confounders Number of mediators
Maternal outcomes
Case control (Stacey et al.,
2011) Still birth and disturbance 3rd 467 - - 2.42 1.46 to
Table 3-17 Summary of adjusted and unadjusted ORs of studies that examined the relationship between daytime sleepiness and poor pregnancy outcomes.
Study design Reference Pregnancy outcomes Trimester Sample size Unadjusted OR 95% CI Adjusted OR 95% CI
Temporal functional group (TFG)
Adjusted variables Number of FTGs Number of mediators Number of confounders
Maternal outcomes
2013) Vaginal delivery Not
specified 1000 1.09 1.02 to
1.16 1.08 1.01 to
1.15 42, 43 2 0 2
Neonatal outcomes
Case control (Stacey et al.,
2011) Still birth 3rd 467 1.78 1.18 to
Table 3-18 Summary of adjusted and unadjusted ORs of studies that examined the relationship between sleep position and poor pregnancy outcomes.
Reference Pregnancy outcomes Trimester Sample size Sleep position Unadjusted OR 95% CI Adjusted OR 95% CI Adjustment
Temporal functional group
Number of TFGs Number of mediators Number of confounders
Maternal outcomes No studies were resulted Neonatal outcomes
Case control
(Stacey et al., 2011)
Still birth 3rd 467 Supine 3.28 1.46 to
7.34 - - Unadjusted 0 0 0
3rd 467 Right side 1.88 1.14 to
3.10, - - Unadjusted 0 0 0
3rd 467 Other
positions 2.00 1.20 to
3.33 - - Unadjusted 0 0 0
(Gordon et
al., 2015) Still birth 3rd 295 Supine 5.00 1.50 to
16.5 6.26 1.20 to 34
Not reported
Not reported
Not reported
Not reported Retrospective
longitudinal
(Owusu et al., 2013)
Still birth Not
specified 234 Supine - - 8.00 1.50 to
43.20 1, 31, 44 3 0 3
Low birth
weight 234 Supine - - 2.00 1.20 to
3.33 1, 31, 44 3 0 3