What are the management strategies for pregnancy in women with Polycystic Ovary Syndrome (PCOS)?

Management Strategies for Pregnancy in Women with PCOS

Women with PCOS require comprehensive preconception assessment, lifestyle optimization, and close monitoring throughout pregnancy due to their increased risk of pregnancy complications including gestational diabetes, preeclampsia, and preterm birth. 1, 2

Preconception Management

Risk Assessment and Screening

• Screen for modifiable risk factors before conception:
  • Blood glucose: Perform 75g oral glucose tolerance test 2
  • Blood pressure: Assess for hypertension 1
  • Weight status: Calculate BMI and assess for obesity 1, 2
  • Metabolic parameters: Complete fasting lipid profile 1
  • Thyroid function: Check TSH levels 1

Lifestyle Modifications

• Weight management is critical for overweight/obese women with PCOS:
  • Target 5-10% weight reduction through 500-750 kcal/day deficit 1
  • Recommend 150 minutes/week moderate intensity or 75 minutes/week vigorous activity 1
  • Implement behavioral strategies: goal-setting, self-monitoring, stimulus control 1
  • Encourage low glycemic index diet rich in fiber and omega-3 fatty acids 1, 3

Medical Management

• For women attempting conception with anovulation:
  • Letrozole is first-line pharmacological treatment for anovulatory infertility 2
  • Clomiphene citrate is an alternative with 80% ovulation rate and 50% conception rate 1
  • Consider low-dose gonadotropin therapy if first-line treatments fail 1
  • Metformin may be used as adjunct therapy for women with insulin resistance 1, 2
    • Discontinue during acute illness with dehydration 1
    • Not recommended for routine ovulation induction without glucose intolerance 4

Pregnancy Management

First Trimester

• Early screening for hyperglycemia:
  • 75g oral glucose tolerance test within first 20 weeks if not done preconception 2
  • Continue monitoring weight, blood pressure, and mental health 2

Second Trimester

• Repeat glucose tolerance test at 24-28 weeks of pregnancy 2
• Monitor for signs of pregnancy-induced hypertension and preeclampsia 3, 5
• Regular blood pressure monitoring every 6 months 1

Third Trimester

• Increased surveillance for:
  • Preeclampsia: More frequent blood pressure monitoring 3, 5
  • Fetal growth restriction: Serial ultrasounds as indicated 2, 5
  • Preterm labor: Be vigilant for early signs 2, 5

Special Considerations

Oocyte Donation Pregnancies

• Consider as high risk and manage in appropriate obstetric unit 6
• Encourage disclosure of pregnancy origin to obstetric team 6
• Base antenatal aneuploidy screening on age of oocyte donor 6

Spontaneous Pregnancies

• Reassure that spontaneous pregnancies after idiopathic POI generally don't show higher obstetric risk than general population 6

Postpartum Care

• Continue monitoring for metabolic complications
• Resume appropriate contraception if desired
• Provide support for breastfeeding

Common Pitfalls and Caveats

• Failure to recognize PCOS as an independent risk factor for pregnancy complications 2
• Overlooking mental health aspects of PCOS during pregnancy 2
• Continuing metformin during acute illness with dehydration 1
• Neglecting lifestyle modifications in favor of pharmacological interventions alone 3
• Insufficient monitoring for pregnancy-induced hypertension and preeclampsia 3, 5

By implementing these management strategies, healthcare providers can help optimize outcomes for both mother and baby in pregnancies complicated by PCOS.