Preprint: Post-viral fatigue following SARS-CoV-2 infection during pregnancy: a longitudinal comparative study, 2022, Oliveira, Nacul et al

[Wyva]

Abstract

Background: Several studies have reported post-COVID-19 fatigue in the general population, but none explored post-COVID-19 fatigue among pregnant women. The objectives of this study were to determine the prevalence over time, duration and risk factors of post-viral fatigue among pregnant women infected with SARS-CoV-2.

Methods: Longitudinal comparative study involving 588 pregnant women with SARS-CoV-2 investigation during pregnancy or at delivery in Sao Paulo, Brazil. Three groups were investigated: G1 (N=259) women with COVID-19 (symptomatic SARS-CoV-2 infection) identified during pregnancy; G2 (N=131) women with positive SARS-CoV-2 serology determined at delivery; G3 (N=198) women with negative SARS-CoV-2 serology at delivery.

Questionnaires investigating fatigue were applied at 6 weeks, 3 and 6 months after SARS-CoV-2 identification for G1; and at delivery, 6 weeks, 3 and 6 months after delivery for all groups. The prevalence of fatigue, fatigue most of the time, and significant fatigue were determined at all timepoints. Cox regression analysis was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) to evaluate the risk of remaining with fatigue over time in G1 women.

Results: Prevalence of overall fatigue in G1 women at 6 weeks, 3 and 6 months were 40.6%, 33.6% and 27.8%, respectively. The cumulative risk of remaining with fatigue increased over time according to the severity of disease, with HR of 1.69 (95%CI: 0.89-3.20) and 2.43 (95%CI: 1.49-3.95) for women with moderate and severe symptoms, respectively. In multivariate analysis, the independent risk factors of fatigue in G1 women were cough and myalgia. At and after delivery the prevalence of fatigue was significantly higher in G1 women compared to G2 and G3 women at all time points.

Conclusions: The prevalence of post-viral fatigue is higher in pregnant women acquiring SARS-CoV-2 during pregnancy, and the risk and duration of fatigue increase with severity of infection.

Open access: https://www.researchsquare.com/article/rs-1629974/v1

 

[Trish]

It's a pity they didn't have an age matched group of non pregnant women as a control group so they could see whether pregnancy itself had any relevance to the findings.

 

[Sly Saint]

article
write up about the study
Persistent fatigue post-COVID-19 in pregnant women

https://www.news-medical.net/news/20220627/Persistent-fatigue-post-COVID-19-in-pregnant-women.aspx

 

[Hutan]

It's good that someone thought to do this study - I assume there will be a followup.

Fatigue

It's a pity they didn't have an age matched group of non pregnant women as a control group so they could see whether pregnancy itself had any relevance to the findings.

Or indeed child care in those early months. I don't know many mothers who aren't exhausted up to the three month mark, and even the 6 month mark, especially if they also have a paid job. A lot of data was gathered, but they don't seem to have investigated the impact of major causes of normal fatigue e.g. employment, numbers of children under the mother's care, lack of family support

Assessing fatigue through answers to this question would be particularly hard for a first time mother whose life will have completely changed following the birth:

‘Fatigue most of the time’ was considered when the patient indicated feeling fatigue more than 50% of the time and when they needed to substantially reduce some activities or could no longer do some routine activities.

I didn't see any reference to PEM, or anything like it, which is a shame and surprising given Luis Nacul's involvement.

(The article has at least one thing wrong - reporting the fatigued percentages of G1 women as the fatigued percentages of all participants.)


Dropouts

30.1% (177/588) participants attended at least three visits.

That's a pretty low percentage. The supplementary table gives more information. Look at Group 1 - that's the women diagnosed with Covid during their pregnancy. 44% had one visit only - and yet the trial design aimed to have them assessed potentially 7 times. That surely puts a lot of uncertainty about the results.

Questionnaires investigating fatigue were applied at 6 weeks, 3 and 6 months after SARS-CoV-2 identification for G1; and at delivery, 6 weeks, 3 and 6 months after delivery for all groups.

Birth method
As an aside - What the hell is going on in Brazil with that rate of cesarean deliveries? More than 60%! In my country (NZ), the rate is less than 30%, and I'm surprised it is that high. Here's rates in Scandinavia which are in line with WHO recommended rates :

Between the first and the last time period studied, the total cesarean rates increased in Denmark (16.4 to 20.7%), Norway (14.4 to 16.5%) and Sweden (15.5 to 17.1%), but towards the end of our study, the cesarean rates stabilized or even decreased.

Surely a rate that high in Brazil is a waste of medical resources and is causing worse outcomes for the mother? If I was the Health Minister of Brazil, or even just in a women's rights group there, I'd be looking hard at what is going on and trying to get the situation changed. Ah, here's an article about the issue if you are interested in reading further, doesn't sound good.
The Atlantic - why most Brazilian women get c-sections

 

[shak8]

Those figures are shocking. Defies rational standard of care for deliveries.

 

[Hutan]

Anyway, back to the results of the study:



Note this is just for the G1 group, who got Covid during their pregnancy. Have a look at the definitions of fatigue. Only a handful of the 259 women were reporting fatigue that resulted them doing half or less than half as much as before the onset of fatigue. By 6 months after infection, only one woman was reporting fatigue that would not disappear with rest.

Without any assessment of PEM, I'm not sure that this tells us much at all.

In symptomatic women infected during pregnancy (G1), the cumulative risk of remaining with fatigue increases over time according to the severity of the disease

In this study, we have investigated factors that may influence the risk of having post-viral fatigue when SARS-CoV-2 is acquired during pregnancy. The most significant factor was the severity of initial disease, with patients admitted to ICU having the highest risk, while no risk was observed for infected women without symptoms.

So, I'm not sure that I'm reading it right, but I think this chart is saying, women who had a severe bout of Covid-19 during their pregnancy had a higher chance of remaining fatigued at the 90 day/three month mark than women with a milder illness. But it looks to me as though all the women with severe disease were recovered at the 210 day/7 month mark. Whereas it's the women with mild illness who had fatigue lingering out beyond that, even to the 330 day/11 month mark.

I think it's interesting that of these 178 women, none appear to have remained fatigued at the one year mark. Of course 178 women is a small sample to pick up cases of ME/CFS. But, there is no evidence that being pregnant while having Covid-19 results in a big risk of getting ME/CFS. I certainly wouldn't be concluding from this that a serious case of Covid-19 makes you more likely to get lingering post-viral fatigue out beyond the 6 month mark than a mild case.

I think the conclusion that the paper has made about the influence of illness severity on fatigue, and specifically post-viral fatigue, is not nuanced enough. It does not discriminate between the sort of fatigue we might expect in a woman who has gone through a difficult illness and pregnancy, versus a post-viral fatigue condition.

 

[Wyva]

Birth method
As an aside - What the hell is going on in Brazil with that rate of cesarean deliveries? More than 60%! In my country (NZ), the rate is less than 30%, and I'm surprised it is that high. Here's rates in Scandinavia which are in line with WHO recommended rates :


Surely a rate that high in Brazil is a waste of medical resources and is causing worse outcomes for the mother? If I was the Health Minister of Brazil, or even just in a women's rights group there, I'd be looking hard at what is going on and trying to get the situation changed. Ah, here's an article about the issue if you are interested in reading further, doesn't sound good.
The Atlantic - why most Brazilian women get c-sections

This is also very high in Hungary, one of the highest in Europe: 40%. But it wasn't like this originally, it has only changed in the past few decades. It has of course several reasons probably but here a big contributing factor may be the fact there aren't enough doctors anymore and thus scheduling some births is preferred instead of the randomness of natural birth. I know there are some hospitals now where you can only give birth on certain days (and if it is a different day, then they'll take you to a different hospital that accepts pregnant women for birth - in the countryside that can be quite a distance).

And the reason for the lack of doctors (most kinds of doctors) is that they could earn very little here legally, so a lot of them chose to work abroad or run their own private practice. It is actually more complicated than that, as people have always paid them a lot of money illegally to make sure everything will be fine (especially operations and childbirth etc). This has been pretty much the norm here but also illegal. So doctors' salaries have been raised a bit and we have yet to see if they stay here or not. Also, private healthcare seems to be more and more popular: not because so many people can afford it but because free healthcare has such serious problems.