Pregnancy is a condition where the body undergoes multiple changes to nurture the baby & to sustain the process of childbirth. Any comorbidity or underlying medical condition can increase the chances of complications in this situation.
PCOS, an endocrine disorder that affects 6-10% of women worldwide can make it difficult for women to get pregnant. In fact, it is seen that in women presenting with infertility, approximately 20 percent or higher suffer from PCOS.
Many a times, the women are diagnosed to be having PCOS while they’re undergoing treatment & investigations for infertility.
The characteristic features of PCOS are Amenorrhea ( absence of periods), oligomenorrhea ( delayed periods), hirsutism, obesity, infertility, chronic anovulation, acne etc. However, not all these features will be found in all women suffering from PCOS.
Apart from affecting the fertility of women, PCOS can lead to the development of some complications during pregnancy such as
- Early miscarriage or Abortion.
- Gestational diabetes.
- Pregnancy induced hypertension(PIH).
- Premature delivery.
- Operative or Caesarean delivery.
Why does PCOS affect your pregnancy?
The origin of PCOS involves primary defects in the hypothalamic–pituitary axis, insulin secretion & action, and ovarian function.
Anovulation makes it harder for women to conceive. Some may even need the help of assisted reproductive technology (ART).
PCOS manifests in the form of various metabolic disorders. Elevated androgen levels, high estrogen, low progesterone levels, insulin resistance, visceral obesity hyperinsulinemia, all make up the PCOS puddle.
The clinical manifestation of the typical characteristic features of PCOS can be attributed to the increase in androgen production by the ‘PCOS ovaries’.
In fact, most symptoms of PCOS are a direct result of increased androgen production in relation to estrogen.
Apart from imparting infertility, PCOS also has the capability to complicate your pregnancy.
This is so because PCOS affects pregnancy hormones and can start a cascade of complications during the pregnancy that can be harmful to both the mother and the fetus.
The insulin resistance of PCOS can worsen during pregnancy leading to Gestational diabetes, large dates baby, Macrosomia & increased need for preterm or Caesarean delivery.
Hormonal changes are also responsible for the development of Pre-eclampsia or PIH during pregnancy. These are serious complications that may also affect the liver, kidneys, eyes & multiple other organs in the body.
Complications in pregnancy due to PCOS
1. Early miscarriage or Abortion
Despite various studies going around the world on PCOS and its effect on pregnancy, very little is known about why women with PCOS are more prone to miscarriage and still birth as compared to women without it.
Based on a number of studies that have been conducted, it has been observed that the rate of abortion is higher in women with PCOS as compared to women who do not have PCOS.
Though it is unclear how it happens, the rates of spontaneous abortion in conceptions achieved through the use of ovulation-inducing medications appear to be higher than conceptions occurring spontaneously.
Statistics have shown that as far as 50% of women with PCOS undergoing some kind of medical intervention, suffer from early miscarriage.
It is speculated that one of the reasons for early loss of pregnancy may be due to the elevated levels of LH (luteinizing hormone) in these women.
It is observed that LH seems to affect both the oocyte quality as well as the subsequent pregnancy that follows it.
There are several mechanisms that have been proposed, that might explain how the elevated LH levels actually impairs the fertility.
According to medical research, a rise in the level of LH leads to an increased level of androgens as well.
So far, the answer to early loss of pregnancy in women with PCOS seems to lie in the elevated LH levels.
Apart from theories involving elevated LH levels, Insulin resistance has also been proposed to play an essential role in early miscarriage.
2. Gestational diabetes
Gestational Diabetes or GDM is defined as a condition characterized by an elevated level of glucose in the blood during pregnancy, typically resolving after the birth of the baby.
It is well known that insulin resistance is seen in PCOS. But what many fail to comprehend is the serious adverse effects that this condition may have on the mother and child.
While women with PCOS are not necessarily Diabetic, they have a higher predisposition to it than women without PCOS.
Interestingly, it is observed that insulin seems to augment androgen-producing capabilities of the ovary.
Insulin resistance can give rise to Type 2 Diabetes. This is potential comorbidity that can negatively affect the pregnancy.
Metformin, an anti-diabetic drug, is prescribed in patients with PCOS. It decreases the circulating insulin levels leading to spontaneous ovulation.
GDM causes significant maternal and fetal complications including preeclampsia, polyhydramnios, fetal macrosomia, birth trauma, metabolic complications in newborn and sometimes even prenatal death.
Development of obesity and diabetes in offspring during childhood and later development of diabetes mellitus in the mother are also related to GDM.
If GDM is not controlled by normal means, medications like metformin may be prescribed to lower the plasma androgen levels so as to avoid PCOS-induced pregnancy complications.
Metformin is an anti-diabetic drug given to women with PCOS to control the insulin resistance pathophysiology of the disorder. During pregnancy, if the mother suffers from uncontrolled GDM, she may be prescribed metformin and/or insulin to control the blood sugar levels.
Preeclampsia is a pregnancy complication that is characterized by the development of hypertension along with proteinuria (increased levels of protein in the urine) after the 20th week of pregnancy in a previously normal woman who did not have hypertension earlier.
The blood pressure increases as high as 140/90 mmHg or more.
Risk factors for pre-eclampsia
- Multiple pregnancies.
- Family history of hypertension or pre-eclampsia.
- Placental abnormalities.
- Any pre-existing vascular disease.
- New paternity or pregnancy following ART.
Complications of Pre-eclampsia
- Fetal growth restriction.
- Preterm birth.
- Placental abruption.
- HELLP syndrome.
- Cardiovascular disease.
- Other organ damage.
4. Pregnancy-induced hypertension (PIH)
PIH is defined as an elevation in blood pressure greater than 140/90 mm Hg without proteinuria. An increase in both systolic blood pressure and diastolic blood pressure maybe seen. It is classified as:
PIH can cause major maternal, fetal and newborn morbidity and mortality.
Women with PIH are at a greater risk of abruptio placentae, cerebrovascular events, organ failure and disseminated intravascular coagulation.
Intrauterine growth retardation, prematurity and intrauterine death are some of the complications that may be conferred to the babies of the mothers suffering from PIH.
Treatment of PIH depends on various factors like
- Blood pressure of the mother.
- Duration of pregnancy.
- Presence of symptoms and associated risk factors.
5. Operative or Caesarean delivery
As the basic pathology of PCOS includes insulin resistance & may lead to the development of Obesity & Gestational diabetes during pregnancy, the possibility of a normal vaginal delivery decreases.
This is so because the size of the baby may become too large to deliver vaginally or sometimes, the shoulders of the baby may get stuck in the pelvis during vaginal birth. This necessitates the use of instruments, forceps/vacuum or even a caesarean section to deliver the baby.
6. Preterm birth
Pregnant women are more likely to develop vaginal infections because of compromised immunity during pregnancy.
In PCOS women, the increased insulin resistance & gestational diabetes may further increase the chances of vaginal infections which may precipitate the onset of premature labour & premature leakage of water from the amniotic sac.
As a result, the incidence of preterm vaginal birth is higher in PCOS women and the babies are more likely to stay in the Neonatal ICU /Nursery for a prolonged duration.
Thus, the possibility of complications is higher in women with PCOS who are pregnant. However, all hope is not lost. It is possible to manage most complications if you are vigilant about the diet & fitness regime during pregnancy and take regular antenatal check-ups.
Be sure to follow your doctor’s advice & keep a close watch on your BP, blood sugar values and any signs of bleeding/abnormal vaginal discharge. A good night’s sleep is also essential for managing the stress & hormonal imbalances that lead to PCOS.
PCOS women are three times more likely to suffer a spontaneous miscarriage as compared to women who do not have PCOS.
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