How does PCOS affect maternal health?
According to the 2020 article on Pregnancy Outcome[s] in Women with PCOS, individuals with PCOS are at increased risk of a variety of adverse maternal and perinatal outcomes.
Polycystic ovarian syndrome (PCOS) is one of the most common, most profound and most overlooked health conditions affecting individuals assigned female at birth. It is a multi-system disorder which impacts hormonal, menstrual, reproductive/maternal, cardio-metabolic, oncological, mental/neurological, sexual and immune system health. In this article we explore the link between PCOS and Maternal Health.
Maternal health refers to the physical, mental and emotional welling of women across the pre-conception, pregnancy, childbirth and postpartum period. Individuals with PCOS are at increased risk for certain conditions across the spectrum of maternal health.
Pre-conception
At its core, PCOS is associated with abnormal functioning of the system of hormones that connects the hypothalamus, the pituitary and the ovaries (the HPO-axis).[1] This interferes with the delicate interplay of hormonal interactions responsible for normal functioning across the menstrual cycle. As a result, PCOS is responsible for 70% of cases of anovulation,[2] where the egg does not release, or ovulate, from the ovaries during the menstrual cycle.[3] Anovulation is responsible for c.30% of cases of infertility[4] and up to 70% of individuals with PCOS struggle with infertility.[5]
Individuals with PCOS are often at risk of some nutritional deficiencies which may increase underlying maternal health risks; these include:
Vitamin B6, B9 (folic acid) and B12: PCOS is associated with Vitamin B deficiency but no causal link has yet been found;[6]
Vitamin C: PCOS is associated with chronic, low-grade inflammation so that Vitamin C, that acts as an antioxidant, is depleted combatting free radicals (highly reactive, unstable molecules);[7][8]
Vitamin D: PCOS is often associated with an accumulation of adipose tissue (body fat) which stores Vitamin D and therefore makes it less available in the blood;[9]
Magnesium: PCOS is associated with hyperinsulinemia, an elevated level of insulin in the blood,[10] and it has been theorized that magnesium deficiency is linked to elevated insulin;[11]
Selenium: similar to Vitamin C, selenium is an anti-oxidative and may be used up combating oxidative stress;[12] and
Zinc: some studies have found that individuals with PCOS have a lower zinc level but more research is needed.[13]
Pregnancy
PCOS is associated with hyperandrogenism (HA) or androgen excess (AE), an elevated level of androgens in individuals assigned female at birth. In early pregnancy, these elevated androgens interfere with the implantation process, where the blastocyst (the cluster of dividing cells made by a fertility egg that develops into a fetus) attaches to the uterine lining.[14] Elevated androgens also interfere with the process of fibrinolysis, the breakdown of clots in the formation of the placental bed.[15][16] PCOS is therefore associated with an increased risk of both implantation failure and placental insufficiency, where the placenta doesn’t deliver enough oxygen and nutrients to the fetus.[17]
Individuals with PCOS are also at increased risk of obesity and make increased use of assistive reproductive technology, both independently associated with increased risk of miscarriage.[18][19] Individuals with PCOS 3x more likely to experience miscarriage,[20][21] the sudden loss of pregnancy before the 24th week.[22] PCOS is also associated with recurrent pregnancy loss (RPL), 3 or more consecutive pregnancy losses before the 24th week.[23]
Elevated androgens disrupt the way that adipose tissue, the body fat or connective tissue that extends throughout your body,[24] metabolizes glucose.[25] An estimated 65-70% of individuals with PCOS develop insulin resistance (IR),[26] where the muscles, fat and liver can’t easily absorb glucose from your blood.[27] During pregnancy, a number of hormones are produced that induce insulin resistance to ensure sufficient glucose to support the growing fetus; these hormones include cortisol, progesterone and placental estrogen, human chorionic gonadotropin (hCG), pro-inflammatory cytokines (e.g., TNF-a) and human placental lactogen (hPL).[28] These hormones exacerbate the pre-existing insulin resistance in individuals with PCOS and, as a result, the prevalence of gestational diabetes mellites (GDM) in individuals with PCOS could be as high er c.60%.[29]
Individuals with PCOS are at a1.4x increased risk of developing pre-eclampsia, a serious condition characterized by high blood pressure that can lead to organ damage and seizures.[30] Whilst the exact mechanism is unknown, some have proposed that problems with placental development, vascular/endothelial dysfunction and/or inflammation may be involved.[31]
Childbirth
Individuals with PCOS often exhibit chronic low-grade inflammation.[32] This inflammation can lead to endothelial dysfunction, where the single cell layer that lines the blood vessels constricts or narrows when they should be dilating or opening.[33][34] This endothelial dysfunction affects the lining of maternal and placental blood vessels and, through an as yet unknown mechanism, can lead to pre-term birth, as well as other pregnancy complications.[35][36] Individuals with PCOS are therefore at 2.0-2.4x the risk of pre-term birth,[37][38] defined as babies born alive before 37 weeks of pregnancy.[39]
Endothelial dysfunction is also a key factor in fetal growth restriction (FGR)[40] and some studies have found a link between PCOS and an increased prevalence of low birth weight or small-for-gestational-age (SGA) offspring.[41]
Other studies have found that there is a link between PCOS and increased prevalence of high birth weight or large-for-gestational age (LGA) offspring,[42] likely due to pre-existing insulin resistance, elevated maternal weight gain and increased prevalence of GDM.[43]
Offspring of PCOS mothers are also at increased risk of meconium aspiration, where a baby inhales their first stool into their lungs during or after birth, and having a low Apgar score, a rapid assessment of newborn well-being at 1 and 5 minutes after birth.[44]
Postpartum
As mentioned above, PCOS is associated with IR, increased risk of GDM and increased risk of high birth weight. GDM can lead to inadequate blood flow to tissues and organs[45] and result in uterine arteriovenous malformations (AVMs) and pseudoaneurysms, abnormal connections or ruptures within the uterine blood vessels.[46] GDM can also lead to changes in platelet adhesion,[47] the process in which platelets in the blood stick to the site of a blood vessel injury.[48]
High birth weight or fetal macrosomia can result in a more difficult labor with risks such as shoulder dystocia (where the baby's shoulder gets stuck), prolonged labor, severe vaginal tearing, postpartum hemorrhage, and uterine rupture as well as increasing the risk that the uterus does not contract after delivery.[49] As a result of these effects, PCOS is associated with increased risk of postpartum hemorrhage (PPH), a serious condition where a woman has significant blood loss in the days or weeks following childbirth.[50]
Individuals with PCOS are at increased risk of mood disorders such as depression and anxiety as well as pregnancy and childbirth complications. Perhaps unsurprisingly, they are also at higher risk for post-partum depression (PPD) (also known as perinatal depression), a mood disorder which may be experienced by pregnant or postpartum women.[51]
PCOS is associated with an elevated level of gestational dehydroepiandrosterone-sulphate (DHEA-S),[52] a type of androgen or male sex hormone produced within the adrenal glands at the top of each kidney.[53] This increases the level of estrogen in the placenta, temporarily interfering with the transition from colostrum to milk. In combination with the other physical and emotional complications, PCOS is associated with low milk supply during early postpartum period and breastfeeding challenges.[54][55]
In combination with pre-existing hypertension (high blood pressure) and diabetes, GDM, pre-eclampsia/eclampsia and fetal growth restriction are known as hypertension disorders of pregnancy (HDP). Post-pregnancy individuals who experience HDP are at increased risk for the development of risk factors for cardiovascular disease, premature cardiovascular disease, chronic kidney disease and cardiovascular mortality.[56]
Overall risk factors for maternal health include:[57][58]
Advanced maternal age;
Having Native Hawaiian, Pacific Islander, American Indian/Alaska Native or Black ethnicity;
Pre-existing chronic diseases such as lupus, multiple sclerosis (MS), diabetes or uterine fibroids;
Thyroid disease;
Kidney disease;
Uterine abnormalities or damage to the uterus due to prior surgery and/or procedure;
Infectious diseases including Zika virus, HIV/AIDS, rubella (measles), tuberculosis and sexually transmitted infections (STIs);
Blood clotting disorders;
Obesity;
Hypertension (high blood pressure);
Use of tobacco, alcohol and/or illegal drugs;
Mental health disorders, including depression and substance use disorders;
Unsafe living condition, including exposure to intimate partner violence; and
Poor access to healthcare.
Note that individuals with PCOS are also at increased risk of a number of these co-morbid conditions, including uterine fibroids, thyroid disease, kidney disease, hypertension and mental health disorders.
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Causes - Maternal