While there is no such thing as a risk-free pregnancy, women with PCOS are at a higher risk of experiencing pregnancy-related complications. On top of the myriad of the unpleasant symptoms of PCOS on a day to day basis, there are some PCOS and pregnancy risk factors that you should be aware of..
Learning about pregnancy risk and PCOS is the first step in keeping yourself and your baby healthy, happy, and safe. Having PCOS does not mean you cannot have a baby and pregnancy can indeed be a wonderful journey. But as you try to conceive, you may be wondering, “How does PCOS affect pregnancy and what pregnancy risks are there for women with PCOS?”
Women with PCOS have an increased risk for pregnancy complications such as difficulty conceiving, early pregnancy loss, gestational diabetes, preeclampsia and other hypertensive disorders, preterm deliveries, complicated labor and delivery, and difficulty breastfeeding.
Important Information, Not Future Predictions
It is important to remember that just because you have PCOS does not mean that all of these risk factors will occur to you during your pregnancy. Learning about potential risks does not doom you to have an incredibly complicated pregnancy and birthing experience. Instead, this information should be viewed as an extra resource for potential problems. The intent of this article is not to scare off any women with PCOS from trying to conceive – we want to educate, inspire, and promote safety for our future PCOS moms!
What are Common Pregnancy Risks in Women PCOS?
No pregnancy is risk-free, regardless of pre-existing health conditions. Creating a human being is no easy feat. During the nine-month gestation period, pregnant women are at a higher risk of developing various health conditions such as gestational diabetes, preeclampsia (dangerously elevated blood pressure), infections, and birthing complications.
Approximately 8% of all pregnancies involve a complication involving the mother, child, or both (1). Women with pre-existing health conditions are at a greater risk of having a complication during pregnancy or the birthing process. Mother’s with PCOS are at a greater risk of developing gestational complications.
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How does PCOS Impact Pregnancy?
PCOS is a condition affecting the reproductive system of females, and it affects 6-15% of women worldwide (4). Common symptoms include irregularly prolonged menstruation, elevated androgen levels, and enlarged polycystic ovaries. Each of these symptoms can have an impact on pregnancy risks and complications.
To become pregnant, a woman must ovulate (releasing an egg from her ovary into the fallopian tubes). This released egg travels down the length of the fallopian tube and enters the uterus, where if met by a sperm cell, fertilization occurs. Many hormones are involved in this cycle, including estrogen and progesterone. If any component of this process is impeded (irregular menstrual cycle timing, hormone imbalances, or difficulties with egg release), conceiving can become difficult or result in complications. PCOS impacts these essential areas of early pregnancy, and they are at increased risk for complications during pregnancy.
PCOS and Conception Difficulties
This may not be a specific risk of “pregnancy,” – but it is still an important topic to discuss and understand. Women with PCOS may experience increased difficulty becoming pregnant. As previously mentioned, becoming pregnant is more complicated than it may seem, and involves many different systems to function correctly and at the correct time. Because women with PCOS experience symptoms related to their gynecological health, PCOS impacts their fertility.
Women with PCOS often experience irregular menstrual cycles, which directly impacts their ability to conceive. The menstrual cycle is often considered to be 28 days, divided into phases based on hormonal changes (2). If any of these phases are extended, it reduces the ability of the ovary to develop and release a fully matured egg properly.
Elevated levels of androgens can also have an impact on fertility. Androgens are a group of hormones that belong naturally in both the biological female and male bodies. The most well-known androgen hormone is testosterone, which is heavily associated with the male reproductive system. Women with PCOS have an elevated amount of androgen hormones, which is linked to irregular menstrual cycles and reduced ovulation.
PCOS also can involve developing follicular cysts within the ovaries. These fluid-filled sacs surround the maturing eggs within the ovaries and overtime cause the ovary to swell and become enlarged (3). The follicles surrounding each egg do not damage or cause harm to the egg but can alter or halt ovulation. Limited ovulation impacts fertility.
Despite the increased risk factors, many women with PCOS can become pregnant. If you have been attempting to become pregnant for over one year with no success, it is important to discuss fertility testing and options with your doctor. There are many modern fertility tests and resources available, including assistive reproductive technologies such as in-vitro fertilization (IVF). Do not give up hope!
Potential for Early Pregnancy Loss
Early pregnancy loss or miscarriage is defined as the loss of a non-viable (aka, not yet developed enough to survive outside of the womb) fetus during the first trimester of pregnancy. All pregnancies have a potential risk for early-term miscarriage, but women with PCOS are at elevated risk compared to the remainder of the female population. Common risks for early-term pregnancy loss include fetal chromosomal abnormalities, advanced maternal age, and previous fetal loss (6).
Statistically, early pregnancy loss occurs in 10 – 15% of pregnancies, and this percentage is increased to 30-50% of PCOS pregancies4. Many contributing factors elevate this risk factor for women with PCOS, such as elevated androgen levels, insulin resistance, endometrial dysfunction, and higher levels of adipose (fat) tissue.
Higher than average levels of androgen hormones have been hypothesized to be a cause of the increased rate of early pregnancy loss in PCOS women. Elevated testosterone levels have been associated with repetitive early-term miscarriages and have also been linked to impaired fetal implantation to the uterine wall5.
Insulin resistance is common in women with PCOS. Increased insulin resistance results in an elevation of the amount of insulin being produced (as your body perceives that the lower amount of insulin is not functioning correctly) (4). Elevated levels of insulin have been connected to early pregnancy loss.
The endometrium is the inner layer of the uterus, where implantation occurs during pregnancy. To become pregnant, the fertilized egg must travel into the uterus and embed itself into the blood and tissue lining of the endometrium. Women with PCOS have an increased risk of impaired implantation, which results in early-term pregnancy loss.
Increased adipose tissue or high body mass index (BMI) increases risk during pregnancy, not just in women with PCOS. Because of insulin resistance and hormone imbalances, women with PCOS are more likely to have elevated amounts of adipose tissue. It is unclear how BMI is connected to early-term pregnancy loss. Still, women with higher than average amounts of adipose tissue are at a higher risk for a miscarriage during their pregnancy.
Things to Look For:
Symptoms associated with early-term pregnancy loss include lower back pain/cramping, weight loss, rhythmic contractions (anywhere from 5 to 20 minutes apart), or tissue resembling a blood clot coming out of the vagina. If you experience any of these symptoms during your pregnancy, please seek medical attention.
Gestational Diabetes and PCOS
There are many different types of diabetes. Gestational diabetes is a condition specific to pregnant women only and begins and ends during a pregnancy. Gestational diabetes occurs when women who do not have diabetes develop elevated blood sugar levels during pregnancy. Common risk factors for gestational diabetes include elevated BMI, family history of type II diabetes, gestational diabetes during a previous pregnancy, and PCOS.
Diabetes is a condition involving blood sugar levels and the hormones that control them. Insulin is a hormone created in our pancreas designed to take sugar in our blood (from eating food throughout the day) and convert it into storable substances in our body. Having appropriate blood glucose levels is essential to remaining healthy, and any deviation above or below the average level will result in symptoms. Diabetes is also linked to hypertension.
Insulin resistance is common in type II diabetes and PCOS. When insulin is not able to properly bind with and remove glucose from our bloodstream, a reduction in the functionality of insulin occurs. This results in poorly controlled blood sugar levels and long-term damage to the body. Adipose tissue is primarily linked to reducing the efficacy of insulin in our body.
Gestational diabetes can occur in up to 20% of pregnancies (7). Women with PCOS are at an elevated risk of developing this condition due to their pre-existing insulin resistance. Gestational diabetes can cause complications for both the mother and fetus.
For an expecting mother with PCOS, gestational diabetes can result in an elevated risk for hypertension during pregnancy, a requirement for a caesarean section, and the potential to develop long-term type II diabetes after pregnancy (8).
Risk factors for the fetus of a mother with gestational diabetes include macrosomia (elevated birth weight due to increased growth from excess sugar exposure in the womb), premature birth, breathing difficulties, hypoglycemia after birth, increased risk for stillbirth, and the higher potential to develop type II diabetes later in life (8).
For women with PCOS, insulin resistance can be treated with metformin, which improves the body’s sensitivity to insulin. Metformin is safe to take during pregnancy and can help to control symptoms of gestational diabetes.
Things to Look For:
Symptoms of gestational diabetes include excessive thirst and urination, nausea, fatigue, and the presence of sugar in your urine (which will be tested at early pregnancy check-ups by your doctor). Gestational diabetes screening is regularly done around 24-28 weeks for all pregnancies, but women with PCOS may be tested earlier due to increased risk.
Hypertension, Preeclampsia, and PCOS
Hypertension occurs when the pressure within our blood vessels is elevated. Long-term hypertension causes damage to the circulatory system and can cause cardiac events such as stroke and heart attacks. Normal blood pressure is measured as 120/80, and hypertension is diagnosed as long-term blood pressure at 140/90.
Preeclampsia is a complication of pregnancy-associated with the spontaneous elevation of blood pressure. If untreated, preeclampsia turns into eclampsia, a medical emergency that causes profound damage to the mother’s organs and the fetus. Preeclampsia most often occurs after 20 weeks of gestation but can develop earlier with more significant risk to the mother and fetus.
Risk factors for developing preeclampsia include elevated BMI, preeclampsia in a previous pregnancy, chronic hypertension, elevated material age, multiple pregnancies, IVF, and history of pre-existing conditions such as PCOS, type II diabetes, kidney disease, and blood clotting disorders (9).
Women with PCOS are at an elevated risk of developing preeclampsia during pregnancy, developing preeclampsia results in increased risk to both mother and child.
For women with PCOS, being diagnosed with preeclampsia can result in an elevated risk for developing life-threatening conditions such as eclampsia and HELLP syndrome (hemolysis elevated liver enzymes and low platelet count)9. Both of these conditions are medical emergencies that result in kidney, brain, and cardiovascular organ damage. If left untreated, these conditions can cause seizures and maternal death. Treatment for eclampsia is the early delivery of the baby, even if this results in preterm birth (5).
Risks for the fetus of a mother with preeclampsia include restricted fetal growth and preterm birth due to increased pressure in the arteries connected to the fetus, breathing issues after birth, and an increased for placental abruption (the disconnection of the placenta from the uterine wall resulting in poor fetal outcomes and excessive bleeding) (9).
What to Look For:
Preeclampsia symptoms include proteinuria (protein in your urine sample), severe headaches, nausea, blurry vision, upper abdominal pain, decreased urine output, swelling to lower limbs, and shortness of breath9. Women with PCOS may develop preeclampsia earlier than 20 weeks’ gestation. Seek immediate medical attention if you experience any of these symptoms during your pregnancy.
PCOS and Preterm Deliveries
The average gestation period for a woman is 40 weeks. Preterm birth is defined as birth before 37 weeks’ gestation. Preterm birth results in higher risks for the fetus. Health issues and level of intensive care is dependent upon how preterm a baby is (the earlier, the more interventions needed).
Globally, the preterm birth rate ranges from 5-18% of all births10. Annually, 15 million babies are born before 37 weeks of gestation (10).
Risk factors for having a preterm birth include carrying multiple fetuses (twins, triplets), previous preterm births, IVF, smoking cigarettes or using illicit drugs, infection of the amniotic sac surrounding the baby, being underweight or overweight during pregnancy, increased exposure to maternal stress, and chronic health conditions such as hypertension, diabetes, or PCOS (11).
Women with PCOS are at an increased risk of having a preterm delivery. Common reasons for PCOS preterm births include premature rupture of membranes (where the amniotic sac ruptures before the proper time for childbirth), spontaneous preterm labor with no known cause, and hypertensive conditions preeclampsia and gestational diabetes (12).
When a baby is born preterm, they are at risk for various complications and health conditions. Babies born preterm often are small in size, lack well developed fat reserves, are at a higher risk to develop hypothermia, often have respiratory issues, and can lack sucking and swallowing reflexes (11). Preterm babies are also at an increased risk of developing health conditions later in life.
Things to Look For:
Symptoms of preterm labor occur before your expected due date. Symptoms include a change in vaginal discharge (more discharge, or blood/mucus discharge), pressure in your pelvis like your baby is moving down, cramping and lower back pain, the presence of contractions, and rupture of the amniotic sac (your “water breaking”). If any of these conditions occur, please seek immediate medical attention for both yourself and your fetus. Your fetus may need extra resuscitative assistance after being born.
PCOS and Natural Birthing Complications
There are two options for birthing a baby – vaginal births and caesarean births. Both of these birthing options are natural, beautiful, and result in healthy and happy babies. There is no “better” way to deliver your baby – there is only the safe way. Safety for mother and baby is the top priority, and this will be taken into consideration for birthing styles.
Vaginal birth occurs when a mother births her baby through her vaginal canal. The cervix (the opening of the uterus) dilates to 10 cm in diameter and using powerful muscle contractions, the mother then pushes the baby from the uterus to the outside world.
Caesarean sections are a surgical procedure to remove the baby from the uterus. An incision is made in the lower abdomen through the adipose and muscle tissue. Once through, the surgeon will cut open the uterus and pull the baby out. As this is a surgical procedure, there is a longer recovery time associated with caesarean sections over vaginal births.
There are many reasons why vaginal birth may not be the safest option. Common reasons that a caesarean section will be performed include prolonged labor, fetal distress (low heart rate or decrease in oxygenation), abnormal fetal positioning in the uterus, previous caesarean section, carrying multiple fetuses at once, or maternal chronic health conditions such as hypertension and PCOS (13).
Women with PCOS are at a higher risk for requiring caesarean sections due to the elevated risk for other pregnancy complications. Gestational diabetes and hypertension result in an increased risk of needing a caesarean section for mother and fetal safety.
Caesarean section risks for the mother include postoperative infection of the surgical site, anesthesia reactions, postpartum hemorrhage/bleeding, possible formation of blood clots, surgical injury, and risk for complications in future pregnancies (13).
Fetal health risks associated with caesarean sections are relatively limited and include possible breathing issues immediately after birth and rare injury during surgery (13).
Things to Look For:
Alerting your OBGYN that you have PCOS is essential when making your birth plan. Understanding that an increased risk for requiring a caesarean section is critical before the birth to your child. Discussing fetal safety during delivery with your health provider is recommended to ensure the best possible birthing experience from mother and baby.
Breastfeeding and PCOS
After birth, the mother’s body gets busy producing breast milk for her new baby. Breast milk alone can sustain a baby’s growth for many months and is naturally occurring. The technique for breastfeeding can be challenging to master, and some medical conditions can impact the success rate of breastfeeding.
Breastfeeding your baby has many benefits for mother and baby. Continual skin-to-skin contact between mother and baby improves the connected bond. Antibodies to fight off illnesses and strengthen the immune system are passed through breast milk to the baby. Babies who are breastfed experience less diarrhea, ear infections, and respiratory infections than babies who are formula-fed (14).
There are many reasons why mothers choose not to or cannot breastfeed their babies. Risk of transmitting infectious diseases, non-breastfeeding safe medication or illicit drug use, and insufficient breast milk production are reasons why a mother may not breastfeed.
PCOS is linked to a reduced quantity of breast milk production. The formation of breast milk is based on the hormones insulin, progesterone, and estrogen (15). Women with PCOS experience altered levels of these hormones, which in turn impacts breast milk production. Lower levels of these hormones are hypothesized to influence mother breast tissue function.
Signs of low breast milk production include poor weight gain or weight loss of your baby after the first three days, limited wet or dirty diapers, and signs of dehydration in your baby (dark urine, jaundiced skin, and lethargy) (16).
Women with PCOS may find that they need to formula-fed their baby to supplement lost calories from inadequate milk production. To encourage more breast milk production, it is advised for PCOS mothers to pump for 10-15 minutes on each breast after a feed (15). This will stimulate more breast milk production in the early stages of breastfeeding.
Things to Consider:
There is nothing wrong with formula-feeding your baby if you have insufficient breast milk supply. Many babies are formula-fed worldwide, and there has been no clear indication that this is the wrong choice for your baby. Understanding and realizing the risk of reduced breast milk production is vital for your baby’s safety. Talk with your health provider if you notice symptoms of limited breastmilk production in your baby.
PCOS Women Do Have Healthy Children!
Yes, women with PCOS are at an elevated risk for many different pregnancy complications and risks. But this does not mean they cannot have happy, healthy babies!
PCOS is becoming more common within our society, and yet our population continues to grow. Becoming pregnant with PCOS is possible and can be safe for both mother and child.
Treating your PCOS symptoms can significantly reduce your risk of pregnancy complications. Managing your weight through controlling your diet, increasing exercise, and taking medications can help reduce the impact of PCOS on your life and pregnancy.
You are not doomed to an incredibly complicated and difficult pregnancy. Education about risk factors and learning about treatment options is the first step to improving PCOS pregnancy outcomes and reducing complications.
Working with your doctor to manage your PCOS symptoms before conceiving can significantly reduce your risk for PCOS related pregnancy complications.
Putting It All Together
Overall, women with PCOS are at an elevated risk for pregnancy complications and risks.
Because of the nature of PCOS, fertility issues arrive from hormonal imbalances and changes to the ovaries. During pregnancy, an increased risk for early-term pregnancy loss, gestational diabetes, and preeclampsia are present due to insulin resistance and elevated androgen hormone levels. PCOS mothers are at an elevated risk for preterm deliveries and are more likely to require a caesarean section. On top of it all, PCOS women are at high risk for insufficient breast milk supply.
These risk factors impact both mother and child. With proper treatment and monitoring, these conditions can be treated and managed to result in a happy and healthy baby and mother.
No, none of this is fair, and yes, you can overcome these obstacles! You are not alone – there are many resources and health professionals ready to help you have the safest PCOS pregnancy possible.
I would love to hear from you – what are you concerned about with your PCOS pregnancy? What have you tried to help reduce your risks? Please leave a comment below. I would love to hear more about your PCOS and pregnancy journey!
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4 Kamalanathan, S; Sahoo, J. P; Sathyapalan, T. Pregnancy in Polycystic Ovarian Syndrome. INDIAN JOURNAL OF ENDOCRINOLOGY AND METABOLISM, 2013
6 Prager, S; Dalton, V. K; Allen, R. H. Early Pregnancy Loss. AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS, 2018
12 Yamamoto, M; Feigenbaum, S. L; Crites, Y; et al. Risk of Preterm Delivery in Non-Diabetic Women with Polycystic Ovarian Syndrome. JOURNAL OF PERINATOLOGY. 2013