Good News & Bad News: Pregnancy Complications in PCOS
Guest post by Rashmi Kudesia, MD MSc
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. Kudesia is a board-certified Reproductive Endocrinology and Infertility specialist, practicing at Houston IVF in Houston, Texas. She joined Houston IVF in 2018 after practicing in New York City, where she was named a “New York Super Doctors Rising Star” in 2016 and 2017.
After completing her Baccalaureate degree in Biology & Medicine magna cum laude from Brown University, she received her M.D. with honors from the Duke University School of Medicine, where she was selected into a clinical research training program co-sponsored by the National Institutes of Health. Her residency training in Obstetrics & Gynecology at the New York Hospital-Weill Cornell Medical Center was followed by subspecialty training in Reproductive Endocrinology and Infertility (REI) at the Albert Einstein College of Medicine-Montefiore Medical Center, alongside a Masters’ of Science degree in Clinical Research Methods. She subsequently served as a Clinical Assistant Professor at the Icahn School of Medicine at Mount Sinai, as well as the Research Rotational Director for the REI fellowship, and Medical Director of the Brooklyn office of the Reproductive Medicine Associates of New York.
Dr. Kudesia is a Fellow of the American College of Obstetricians and Gynecologists, and an active member of the American Society for Reproductive Medicine (ASRM), Society for Reproductive Endocrinology and Infertility, Androgen Excess & Polycystic Ovary Syndrome Society, and American Medical Association (AMA). She has served in multiple local and national leadership roles in organized medicine, including her current positions as Secretary of the ASRM Women’s Council Executive Board and the ASRM delegate to the AMA Young Physicians’ Section.
Dr. Kudesia has also presented scientific research at national and international conferences, and has received multiple awards and grants for her work. She has published peer-reviewed articles and book chapters, including in leading journals such as Fertility & Sterility and the American Journal of Obstetrics & Gynecology, as well as editing a theme issue on reproductive medicine for the American Medical Association Journal of Ethics. Her current areas of focus include improving in vitro fertilization cycle prognosis, polycystic ovary syndrome, LGBT fertility, and fertility awareness, counseling, and access to care. She actively promotes women’s health and wellness on social media via Twitter, Facebook, and Instagram.
Currently pregnant with #2 with PCOS. First pregnancy, I was diagnosed with gestational diabetes but was entirely diet-controlled and Baby #1 was born with only slightly off sugar levels. This time around, I DON’T have gestational diabetes. Both times, I had polyhydramnios (too much amniotic fluid) and babies that measure big for gestational age. When Baby #1 was close to induction date (“She’s big, you have GDM, you have poly, let’s induce and monitor closely), she measured in-utero at 8lbs 13oz. She was born via emergency c-section (water broke, she went into distress, time to go get baby) at 7lbs 9oz. Baby #2 is measuring at 6lbs 9oz at 34wks gestational age (supposed to be around 4lbs), but due to my history, I’m going with he’s closer to 5.5 lbs.
So, one with GDM, one without. Both measuring big: one who didn’t come out anywhere close to estimate and one to-be-determined.
All of this to say, PCOS affects pregnancy because PCOS messes with the endocrine system and pregnancy messes with the endocrine system. They are bound to get in a fight over who should win. Each placenta is going to emit different hormones and, while PCOS is certainly nothing to discount, I don’t think PCOS by itself is going to guarantee you a certain kind of pregnancy. Your body and your choices during pregnancy (and before) will do more to determine your pregnancy experience. Risks are good to know about, but don’t dwell on them and CERTAINLY don’t plan on them. Be aware, be smart, and try to enjoy being pregnant!