Guest post by Rashmi Kudesia, MD MSc
Reproductive Endocrinologist and Infertility Specialist, RMA of New York
This week, we pick up off of our prior topic regarding miscarriage risk in women with PCOS, and move later into pregnancy to discuss other possible complications that have historically been associated with PCOS. As we described previously, the meta-analysis approach, where exhaustive search techniques are used to sift through previous data relating to the question of interest, and compile it into one summary conclusion, is frequently utilized to explore pregnancy complications in PCOS. As regards the topic of PCOS and pregnancy complications, there have been three large ones, published in 2006, 2011 and 2013, and a wonderful review article published just last year that summarizes the data to-date. Though the results may seem a bit daunting, hang in there until the end for some good news!
The pregnancy complication most obviously and commonly associated with PCOS is gestational diabetes mellitus (GDM). The placenta, once it develops, makes hormones that cause a degree of insulin resistance in all pregnancies. As a result, as many women with PCOS already have an element of insulin resistance, pregnancy can push them into diabetes-level sugar control. Indeed, in the three large meta-analyses, the risk of GDM was about 3-fold higher in PCOS women. Certainly, there are some individual factors that could make some women with PCOS more likely to become diabetic in pregnancy, including older age, being overweight, having other health problems, hailing from high-risk ethnic backgrounds (South Asian, Latino, or Middle Eastern for example) or having a strong family history of diabetes. Indeed, in some larger studies, when the risk is controlled for some of these factors, the overall risk for all PCOS women is still elevated, but not quite as high, closer to a 2-fold increase. So, the risk of GDM is certainly higher for PCOS women, but is particularly so for women with additional risk factors.
For pregnancy-induced hypertension (PIH) or preeclampsia (PE, high blood pressure and high urinary protein in pregnancy), the story is similar. All three meta-analyses demonstrated a 3-4 times higher rate (or 300-400% higher odds) of these conditions, though again additional factors may especially increase the risk. For example, one large Swedish study showed a less impressive elevation in the preeclampsia risk (45% greater odds) after controlling for body mass index (a metric that accounts for height and weight) and the usage of assisted reproductive technologies. So again, the combination of having PCOS and being overweight seems to increase the risk. Furthermore, there is evidence to suggest that PCOS women who have high androgen (male hormone) levels are particularly at risk, even when compared to other PCOS women with normal androgen levels.
These findings regarding GDM and PIH/PE are the most important and the most clearly studied. That said, it is also important to remember that the biggest pregnancy risk, that of prematurity, is imposed by multiple pregnancy, and so choosing a treatment plan with your fertility doctor that decreases that risk is a very critical step in reducing risk. Multiple pregnancy also further increases the risk of both GDM and PIH/PE, so the goal is truly one healthy baby at a time!
Studies that have looked at other pregnancy complications have shown conflicting results. There is no obvious data to suggest a higher rate of Cesarean sections. Two out of the three large meta-analyses showed a 2-fold increased rate of preterm delivery, but the third did not show any such effect. One study suggested that the risk of prematurity was only present in those women with high androgens. Birthweight data has shown that babies born to women with PCOS seem to often be small or large for gestational age, and less likely to be in the normal range. These studies do not do enough to control for premature deliveries, however, and so the evidence is truly too scarce to be confident on the associations between PCOS and birthweight, requirement for neonatal intensive care or perinatal mortality.
So, this summary sounds quite frightening, and honestly, very frustrating! But, though it is tough to get this far and then think about higher complication rates, remember that a planned pregnancy initiated with you in your best possible health, and in partnership with a detail-oriented care team, is the best way to keep your risks as low as possible. Indeed, a large high-quality study published just this summer showed that a short delay in treatment to pursue detailed lifestyle improvements (caloric restriction, exercise, anti-obesity medications as needed) resulted in a 40% higher odds of ovulation and 250% greater odds of a live birth! If you are looking to conceive with PCOS, be sure to talk to your gynecologist or PCOS specialist about your specific risk profile, and what realistic goals might be for you to conceive as healthfully as possible. Check your sugar control prior to conception, visit with a dietitian to discuss a healthy diet during conception and pregnancy, and be sure you receive an early screen for gestational diabetes at around 12 weeks gestation, as well as regular testing for blood pressure and urinary protein at your regular prenatal care visits. Being aware and informed of your health risks is step number one to maintaining a healthy pregnancy, and you are on your way to achieving it!
Dr. Rashmi Kudesia is a reproductive endocrinologist and infertility specialist who leads RMA of New York’s Brooklyn office. Dr. Kudesia specializes in treating couples who are trying to build their families.
Dr. Kudesia earned her medical degree from Duke University. She completed her residency in obstetrics and gynecology at New York Presbyterian Hospital/Weill Cornell Medical College. She completed her fellowship training in Reproductive Endocrinology and Infertility as well as a Masters of Science in Clinical Research Methods at Albert Einstein College of Medicine.
Dr. Kudesia has received numerous grants and awards for her academic accomplishments and medical research. She was awarded a Global Women’s Health certificate by Mount Sinai School of Medicine in 2011, and was nominated into the Duke Engel Society, which recognizes intellectual development, service and clinical excellence. Dr. Kudesia is the recipient of the Joan F. Giambalvo Scholarship Research Grant from the AMA Foundation in 2013, as well as multiple in-training research grants. Dr. Kudesia served as a Theme Issue Editor for the American Medical Association’s Journal of Ethics’ issue on Innovation in Reproductive Care, and has held multiple regional and national leadership positions within organized medicine.
Dr. Kudesia is an accomplished lecturer and author and has written numerous scientific research articles and manuscripts in leading medical journals. She has presented many of her research findings at national meetings, including the American Society for Reproductive Medicine (ASRM).