Chronic Fatigue Syndrome: Implications for Women and Their Health Care Providers During the Childbearing Years

Peggy Rosati Allen, CNM, WHNP, MS, LCCE

Disclosures

J Midwifery Womens Health. 2008;53(4):289-301. 

In This Article

Implications for Clinical Practice

Health care providers are likely to encounter more women in practice with CFS as awareness, education, and diagnostic tools for the illness improve. Although the complexities of establishing initial diagnosis and treatment of CFS are beyond the usual scope of midwifery practice, it is prudent as providers of women's health care to increase awareness and knowledge of this disorder that affects a preponderance of women and so profoundly impacts their lives and the lives of their families. Midwives can initiate initial diagnostic testing in women presenting with symptoms suggestive of CFS with follow-up by internal medicine or other specialists as indicated. Midwives are well-qualified to provide gynecologic and obstetric care to women with CFS with consultation, collaboration, or referral to specialists according to usual guidelines for practice. Collaboration with or referral to the woman's primary care physician for medication adjustment or treatment related to CFS may be necessary.

Preconception

Preconception counseling for a woman with CFS should include explanation of the paucity of evidence regarding the reciprocal effect of pregnancy and CFS. The woman should be encouraged to discuss her plans for pregnancy with her primary care provider and make any adjustments in medications that could have potential adverse effect on pregnancy and lactation. She should be cautioned regarding the potential for a severe CFS relapse postpartum.

Pregnancy

If further study validates the findings of Schacterle and Komaroff[1] and the observations of CFS experts described in this paper, symptoms should either improve or remain unchanged during pregnancy for most women with CFS. The need for CFS treatment should be lessened or similar to pre-pregnancy norms. Referral to physical therapy for muscle and joint pain can be provided, although referral to a physical therapist familiar with the limited exercise tolerance of CFS is important as inappropriate therapy can trigger relapse.[2] Intravenous hydration with normal saline can be considered. While this treatment carries little risk, its indication and benefit for women with CFS during pregnancy is not known. For women with orthostatic intolerance, continuing to wear compression stockings and pushing daily oral fluids may be beneficial in minimizing CFS symptoms as well as pregnancy-related discomforts. Although scientific study documenting the effects of pregnancy on orthostatic intolerance with CFS is lacking, it seems intuitive that physiologic changes of pregnancy including expanded blood volume may improve this symptom.

During pregnancy, the clinician should assess a woman's physical and psychosocial adjustment to pregnancy. As stress from any source, physical or emotional, can exacerbate illness in a person with CFS, measures should be taken to minimize stressors. Increased assistance from a partner or other family and friends with household responsibilities, childcare, or a decrease in employment responsibilities may be especially indicated for women with CFS during pregnancy. Anticipatory guidance for building a strong network of support for the early months postpartum is paramount.

Intrapartum

One could extrapolate that the poor exercise tolerance and propensity for relapse in response to stress that is well documented in CFS predicts greater fatigue ability during and after childbirth in a woman with CFS, although there is no scientific evidence to validate this. The usual recommendations of ambulation and frequent position changes to facilitate labor progress may need to be moderated to conserve energy and prevent relapse in the laboring woman with CFS. Additionally, consideration may need to be given to avoid the vasodilatation effect of overly heated or prolonged showers, baths, or jacuzzis for women in labor with CFS who also have orthostatic intolerance. Continuous intravenous fluid with a volume expander like normal saline or lactated ringers solution seems advisable to maintain hydration and avoid fatigue in the laboring woman with CFS, especially if she is unable to consume much oral fluid.

Although the primary care needs of women with CFS are complex and usually warrant referral or comanagement, midwives are ideally suited to provide care related to pregnancy, childbirth, and postpartum to women with CFS. The "with woman" midwifery philosophy and care practices can result in an increase in a woman's sense of empowerment and satisfaction with her care. In addition, this type of supportive care decreases pain and the associated emotional and physical stress of labor, and decreases the rate of childbirth complications.[58,59] One could easily postulate that all of these benefits of midwifery care in childbirth can decrease the incidence or severity of CFS relapse after childbirth. Epidural anesthesia may also be advisable for women with CFS who have a more prolonged labor. The benefit of elective cesarean for women with CFS to avoid the physical stress of labor has been mentioned in self-help literature,[60] but the advisability of this recommendation is highly debatable.

Postpartum

Whether the woman with CFS chooses to breastfeed or bottle-feed her infant, strong support with nighttime feedings as well as daytime meal preparation, grocery shopping, childcare, and household responsibilities is especially important during the postpartum period. Home health nursing referral may be indicated at hospital or birth center discharge to assess the level of support and adjustment of a woman with CFS once home. Anticipatory guidance for increase in energy conservation measures to avoid the 3- to 6-month postpartum relapse observed by Dr. Klimas may also be helpful.

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