Clinical Management of Pregnancy in Women With Polycystic Ovary Syndrome

An Expert Opinion

Mahnaz Bahri Khomami; Helena J Teede; Anju E. Joham; Lisa J. Moran; Terhi T. Piltonen; Jacqueline A. Boyle


Clin Endocrinol. 2022;97(2):227-236. 

In This Article

Abstract and Introduction


Polycystic ovary syndrome (PCOS) is associated with a higher risk for pregnancy and birth complications according to the specific features associated with PCOS. The features include obesity before and during pregnancy, hyperandrogenism, insulin resistance, infertility, cardiometabolic risk factors, and poor mental health. PCOS is not often recognized as a risk factor for poor pregnancy and birth outcomes in pregnancy care guidelines, while its associated features are. Pregnancy-related risk profile should ideally be assessed for modifiable risk factors (e.g., lifestyle and weight management) at preconception in women with PCOS. Hyperglycaemia should be screened using a 75-g oral glucose tolerance test at preconception or within the first 20 weeks of pregnancy if it has not been performed at preconception and should be repeated at 24–28 weeks of pregnancy. In the absence of evidence of benefit for strategies specific to women with PCOS, the international evidence-based guidelines for the assessment and management of PCOS recommend screening, optimizing, and monitoring risk profile in women with PCOS (at preconception, during and postpregnancy) consistent with the recommendations for the general population. Recommended factors include blood glucose, weight, blood pressure, smoking, alcohol, diet, exercise, sleep and mental health, emotional, and sexual health among women with PCOS. The guidelines recommend Metformin in addition to lifestyle for assisting with weight management and improving cardiometabolic risk factors, particularly in those with overweight or obesity. Letrozole is considered the first-line pharmacological treatment for anovulatory infertility in PCOS. Individualized approach should be considered in the management of pregnancy in PCOS.


OPolycystic ovary syndrome (PCOS) is a common endocrine disorder affecting up to 8%–13% of reproductive-aged women.[1] According to the Rotterdam criteria, PCOS in adults is diagnosed based on a minimum of two of the following: oligo/anovulation, clinical and/or biochemical hyperandrogenism, and PCO morphology on ultrasound, after ruling out differential diagnoses.[2] These criteria result in four phenotypes of PCOS including phenotype A with oligo/anovulation, hyperandrogenism, and PCO morphology; phenotype B with oligo/anovulation and hyperandrogenism; phenotype C with hyperandrogenism and PCO morphology; and phenotype D with oligo/anovulation and PCO morphology. PCOS is associated with metabolic, reproductive, and psychological features.[3] Aetiology is complex including genetic, in-utero, potential epigenetic factors, exacerbated by adverse lifestyle and excess adiposity. Hyperandrogenism, insulin resistance, and resulting hyperinsulinemia are common underpinnings in PCOS.

PCOS and excess adiposity have a bidirectional relationship with excess weight exacerbating the underpinning hormonal imbalance and PCOS itself appearing to predispose to excess weight and weight gain.[4] The prevalence of PCOS in women with obesity is up to 37%.[5] Women with PCOS may also be more likely to gain weight longitudinally[4] and at a greater pace.[6] This may be attributable to impairments in appetite-regulating hormones and hyperinsulinemia.[7] and a more sedentary lifestyle.[8] and may be inter-related to the psychological features of PCOS such as anxiety, depression, and poor quality of life.[9] Obesity further exacerbates hyperandrogenism and hyperinsulinemia and plays a key independent role in increasing cardiometabolic risks in women with PCOS.[10,11]

Women with PCOS commonly have oligo/anovulation, with or without irregular menstrual cycles,[12,13] with PCOS the most common cause of anovulatory infertility.[14] Infertility and a longer time to pregnancy may confer a higher risk for pregnancy and birth complications.[15,16] Additionally, the type and intensity of treatment used to manage infertility, may further complicate pregnancy and birth independent of multiple pregnancies.[15,17] Infertility is exacerbated by obesity.

Women with PCOS are generally at higher risk of pregnancy and birth complications including gestational diabetes (GDM), gestational hypertension, pre-eclampsia, induction of labour, caesarean section, preterm birth, and large for gestational age babies. The association of PCOS with pregnancy and birth complications varies by PCOS phenotype, target population, ethnic background, self or family history of metabolic, reproductive, and potentially psychological complications during or outside pregnancy, and women's lifestyle.[10,18–20] In pregnancy, obesity is an independent risk factor for complications, as is excess gestational weight gain.[10,18,21] Both obesity and increased gestational weight gain are documented in PCOS although whether there is an additional adverse impact of gestational weight gain on pregnancy and birth complications in women with PCOS is not still well understood.[10,18]

While common features of PCOS are recognized as risk factors for pregnancy and birth complications by pregnancy care guidelines,[22] PCOS per se is not consistently perceived as a risk factor for complications in pregnant women with PCOS. Delayed and missed diagnosis is common in the general population[23] and recognition of PCOS as a risk factor in pregnancy and birth complications is even poorer.[24] In this context, we aimed to review the relationships between PCOS and pregnancy and birth complications, the intersecting impact of obesity and excess gestational weight gain, the need to enhance recognition of PCOS before and during pregnancy, and to provide maternity care that meets the needs of this high-risk group. Here, we seek to reflect the evidence assembled for the International evidence-based guidelines for the assessment and management of PCOS and the multidisciplinary recommendations for clinical management of pregnancy in PCOS from the guidelines including risks, screening, pregnancy care, lifestyle, healthy gestational weight gain, and lifestyle in pregnancy.