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org

Pregnancy outcomes in women with polycystic

ovary syndrome: a metaanalysis
Lucinda E. Kjerulff, MD; Luis Sanchez-Ramos, MD; Daniel Duffy, MD

OBJECTIVE: The purpose of this study was to examine which maternal
and neonatal complications are associated with polycystic ovary syn-
drome (PCOS) in pregnant women.
STUDY DESIGN: The studies that were included compared pregnancy
outcomes between women with PCOS and those without diagnosed
PCOS. Our primary outcomes included gestational diabetes mellitus,
pregnancy-induced hypertension, and preeclampsia. Secondary out-
comes included cesarean delivery rates, operative vaginal delivery
rates, preterm delivery, small-for-gestational-age (SGA) infants and
large-for-gestational-age infants.
RESULTS: We found that PCOS in pregnancy was associated with
higher rates of gestational diabetes mellitus, pregnancy-induced hyper-
tension, preeclampsia, preterm delivery, cesarean delivery, operative
vaginal delivery, SGA, and large-for-gestational age. Only gestational
diabetes mellitus, pregnancy-induced hypertension, preeclampsia,
preterm delivery, and SGA infants were found to be statistically
significant.
CONCLUSION: This metaanalysis confirms the higher association of
pregnancy complications and PCOS compared with patients who do not
have PCOS. Additionally, there may be a stronger association between
PCOS and hypertensive disorders than has been shown previously.
Key words: complication, gestational diabetes mellitus, polycystic
ovary syndrome

Cite this article as: Kjerulff LE, Sanchez-Ramos L, Duffy D. Pregnancy outcomes in women with polycystic ovary syndrome: a metaanalysis. Am J Obstet Gynecol
2011;204:558.e1-6.

P olycystic ovary syndrome (PCOS) is

estimated to affect at least 5–15% of
reproductive-aged women and is there-
fore one of the most common endocrine
abnormalities worldwide.1 Despite its
prevalence, PCOS is a disease with an
unclear cause, varying diagnostic crite-
ria, expansive clinical effects, and de-
batable management. In nonpregnant
women, PCOS is known to be associated
From the Department of Obstetrics and
Gynecology, University of Florida College of
Medicine–Jacksonville, Jacksonville, FL.
Presented at the 73rd Annual Meeting of the
South Atlantic Association of Obstetricians and
Gynecologists, Hot Springs, VA, Jan. 30-Feb.
2, 2011.
Received Oct. 4, 2010; revised Feb. 17, 2011;
accepted March 9, 2011.
Reprints: Lucinda Esenam Kjerulff, MD,
Resident Physician (PGY3), 653-1 West 8th
St., Department of Obstetrics and Gynecology,
University of Florida College of
Medicine–Jacksonville, Jacksonville, FL
32246. Lucy.Kjerulff@jax.ufl.edu.
Authorship and contribution to the article is
limited to the 3 authors indicated. There was
no outside funding or technical assistance with
the production of this article.
0002-9378/$36.00
© 2011 Published by Mosby, Inc.
doi: 10.1016/j.ajog.2011.03.021
with menstrual irregularities, decreased
fertility, insulin resistance, diabetes mel-
litus, and hyperandrogenism.2 For this
population to become pregnant, many
women require assisted reproductive
techniques in addition to the medical
treatment of insulin insensitivity.3-5
Once this previously subfertile popula-
tion becomes pregnant, the effect of
maternal insulin insensitivity and hy-
perandrogenism on the fetus must be
considered.
Pregnant women without PCOS have
a natural state of insulin resistance.6,7
With the additive effect of PCOS, this
baseline insulin resistance may worsen
and lead to gestational diabetes mel-
litus and its consequences. Additionally,
women with PCOS have been shown to
have a low amount of insulin-like growth
factor binding globulin-1 that may con-
tribute to preeclampsia and growth ab-
normalities.8 An earlier metaanalysis in
2006 found that women with PCOS had
a significantly higher risk of experiencing
gestational diabetes mellitus, pregnancy-
induced hypertension, preeclampsia,
and preterm birth. Additionally, infants
of women with PCOS also had a signifi-
cantly higher risk of admission to a neo-
natal intensive care unit and a higher
perinatal mortality rate that was unre-
lated to multiple births.9 Since that
report, 8 relevant studies have been pub-
lished, which includes one that has dis-
puted the increased risk of preeclampsia,
preterm delivery, polyhydramnios, oli-
gohydramnios, macrosomia, and ad-
verse infant outcomes.10 In view of these
new reports, we conducted an updated
metaanalysis to reevaluate the risks of
gestational diabetes mellitus, pregnancy-
induced hypertension, preeclampsia, ce-
sarean delivery, preterm delivery, and
operative vaginal delivery.
M ATERIALS AND M ETHODS
We reviewed computerized databases,
references of published articles, and text-
book chapters to find articles that would
meet the inclusion criteria. Comput-
erized databases included MEDLINE
(Pubmed, NLM Gateway) and Cochrane
Library.
Study selection
To examine the association between
PCOS and pregnancy complications, we
searched for studies from 1966 to April
2010 in which outcomes were compared
between women with PCOS and women
without diagnosed PCOS. Because most
of the studies were performed before the
revised 2006 Androgen Excess and Poly-

558.e1 American Journal of Obstetrics & Gynecology JUNE 2011

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www.AJOG.org
FIGURE
Flowchart of study selection
Kjerulff. Pregnancy outcomes and polycystic ovary
syndrome. Am J Obstet Gynecol 2011.
cystic Ovary Syndrome (AE-PCOS) So-
ciety criteria, the 2003 Rotterdam crite-
ria were used to establish the diagnosis of
PCOS. Specifically, the Rotterdam crite-
ria require at least 2 of 3 features of
PCOS: (1) oligomenorrhea and/or an-
ovulation, (2) clinical and/or biochemi-
cal signs of hyperandrogenism, (3) poly-
cystic ovaries on ultrasound scanning.2
The revised 2006 AE-PCOS criteria ex-
cluded patients who were not hyperan-
drogenic with only oligo/anovulation
and polycystic ovaries on ultrasound
scanning from the diagnosis of PCOS
but included the other phenotypes of
PCOS that had been determined by the
Rotterdam consensus.11 Because the
2006 AE-PCOS criteria are inherently
within the definition of the Rotterdam
criteria, these updated criteria were
used as an acceptable alternative to use
to diagnose PCOS in the more current
articles. Our primary outcomes in-
cluded gestational diabetes mellitus,
pregnancy-induced hypertension, and
preeclampsia. Secondary outcomes in-
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cluded cesarean delivery rates, op-
erative vaginal delivery rates, preterm
delivery, small-for-gestational age in-
fants, and large-for-gestational age
infants.
Tabulation and integration
This systematic review was preceded by a
detailed study protocol that stated the
question to be addressed, the subgroups
of interest, and the methods and criteria
to be used for the identification and se-
lection of relevant studies and extraction
and analysis of information. Approval
from the institutional review board
was not required to perform this meta-
analysis. With the use of computerized
databases, references of published sys-
tematic reviews, and textbook chap-
ters, potential articles were found and
reviewed.9,12 Search terms included
PCOS and pregnancy complications,
PCOS and pregnancy outcomes, PCOS
and neonatal outcomes, PCOS and
gestational diabetes mellitus, PCOS
and pregnancy and hypertension,
PCOS and preeclampsia, PCOS and
preterm labor, PCOS and cesarean sec-
tion delivery, PCOS and operative vag-
inal delivery, PCOS and forceps, and
PCOS and vacuum delivery.
Articles that were included for full re-
view required the following information:
(1) assessment of obstetric outcomes in
women with PCOS that had been diag-
nosed by the Rotterdam criteria or the
updated 2006 AE-PCOS criteria, (2)
assessment of obstetric outcomes in
women without PCOS, and (3) met-
formin could not have been used by the
PCOS group after conception. We fol-
lowed the Meta-analysis of Observa-
tional Studies in Epidemiology group
guidelines for analyzing observational
studies in a metaanalysis.13 Two contrib-
utors independently assessed each arti-
cle, and any discrepancies were discussed
with 1 of 2 other contributors.
R ESULTS
Initial broad search results yielded 946
possible articles (Figure). Later, 897 arti-
cles were excluded because of duplica-
tion or irrelevance by title; then 12 arti-
cles were excluded on the basis of the
JUNE 2011 American Journal of Obstetrics & Gynecology
SAAOG Papers
abstract. Of the remaining, 37 articles, 14
articles were excluded because 4 lacked a
comparison group, 2 did not evaluate the
included outcomes, and 8 involved the
use of metformin after diagnosis of preg-
nancy. The final 23 articles that fully met
inclusion criteria were then reviewed,
and data tables were constructed. A total
of 92,392 patients were included in the
metaanalysis (2544 patients with PCOS
compared with 89,848 patients without
PCOS). Table 1 shows the characteristics
of each study. Women with PCOS were
noted to have higher rates of gestational
diabetes mellitus (odds ratio [OR], 2.82;
95% confidence interval [CI], 1.93–
4.10), pregnancy-induced hypertension
(OR, 4.07; 95% CI, 2.75– 6.02), pre-
eclampsia (OR, 4.23; 95% CI, 2.77–
6.46), preterm delivery (OR, 2.20; 95%
CI, 1.59 –3.04), cesarean delivery (OR,
1.41; 95% CI, 0.96 –2.07), operative vag-
inal delivery (OR, 1.56; 95% CI, 0.93–
2.63), small-for-gestational-age infants
(OR, 2.62; 95% CI, 1.35–5.10), and
large-for-gestational-age infants (OR,
1.56; 95% CI, 0.92–2.64). Table 2 sum-
marizes these results. Tables 3-5 specifi-
cally outline the odds ratio for the
primary outcomes. All pregnancy out-
comes, except for gestational diabetes
mellitus, were evaluated with the use of a
fixed-effects model in which the ran-
dom-effects model was used. We used
Stata software (version11.0; StataCorp,
College Station, TX) to perform the
metaanalysis.
C OMMENT
This metaanalysis confirms earlier find-
ings regarding obstetrics patients with
PCOS and also updates ORs for associ-
ated pregnancy complications. Although
women with PCOS were noted to have
higher rates of previously mentioned
outcomes, only gestational diabetes
mellitus, pregnancy-induced hyperten-
sion, preeclampsia, preterm delivery,
and small-for-gestational-age infants
were found to be statistically significant.
Furthermore, when compared with the
2006 study, the ORs increased for preg-
nancy-induced hypertension, pre-
eclampsia, preterm delivery, and small-
for-gestational-age infants (Table 6).
558.e2
SAAOG Papers www.AJOG.org

TABLE 1
Characteristics of included studies
Group, n
Women with
polycystic ovary Control
Study Outcomes included syndrome patients Conception method Study type
Altieri et al14 GDM, PIH, preeclampsia, cesarean 15 159 Spontaneous, ovulation Retrospective
delivery, OVD, PTD, neonatal induction, ART
malformation
................................................................................................................................................................................................................................................................................................................................................................................
15
Hu et al PIH, preeclampsia 22 22 Spontaneous Prospective
................................................................................................................................................................................................................................................................................................................................................................................
16
Li et al Preeclampsia, PTD, macrosomia, 34 70 Spontaneous and ART Prospective
LGA, SGA
................................................................................................................................................................................................................................................................................................................................................................................
17
Maliqueo et al LGA, SGA 30 34 Spontaneous Prospective
................................................................................................................................................................................................................................................................................................................................................................................
18
Palomba et al GDM, PIH, preeclampsia, cesarean 93 69 Spontaneous Prospective
delivery, OVD, PTD, LGA, SGA,
placental abruption
................................................................................................................................................................................................................................................................................................................................................................................
19
Diamant et al Preeclampsia 70 71 Ovulation induction Retrospective
................................................................................................................................................................................................................................................................................................................................................................................
20
Levran et al GDM 76 95 Spontaneous, ovulation induction Retrospective
................................................................................................................................................................................................................................................................................................................................................................................
21
Wortsman et al GDM 53 2306 Spontaneous, ovulation induction Retrospective
................................................................................................................................................................................................................................................................................................................................................................................
22
Cardenas et al GDM 31 78 Ovulation induction Retrospective
................................................................................................................................................................................................................................................................................................................................................................................
23
Urman et al GDM, PIH, preeclampsia, PTD, NICU 47 100 Spontaneous, ovulation Retrospective
admission induction, ART
................................................................................................................................................................................................................................................................................................................................................................................
24
Fridstrom et al GDM, PIH, preeclampsia 33 66 Spontaneous, ovulation Retrospective
induction, ART
................................................................................................................................................................................................................................................................................................................................................................................
25
Radon et al GDM, preeclampsia 22 66 Spontaneous, ovulation Retrospective
induction, ART
................................................................................................................................................................................................................................................................................................................................................................................
Kashyap and PIH 22 27 Spontaneous, ovulation Retrospective
Claman26 induction, ART
................................................................................................................................................................................................................................................................................................................................................................................
27
Vollenhoven et al GDM, PIH, PTD 60 60 Spontaneous, ovulation induction Retrospective
................................................................................................................................................................................................................................................................................................................................................................................
28
Mikola et al GDM, PIH, PTD 80 712 Ovulation induction Retrospective
................................................................................................................................................................................................................................................................................................................................................................................
29
Bjercke et al GDM, PIH, preeclampsia, cesarean 52 335 Ovulation induction, ART Prospective
delivery, OVD, PTD, NICU admission
................................................................................................................................................................................................................................................................................................................................................................................
30
Haakova et al GDM, PIH, cesarean delivery, PTD 66 66 Spontaneous, unspecified ART Retrospective
................................................................................................................................................................................................................................................................................................................................................................................
31
Turhan et al GDM, PIH, preeclampsia, cesarean 38 136 Not stated Retrospective
delivery, PTD, macrosomia,
neonatal malformation, abruption
................................................................................................................................................................................................................................................................................................................................................................................
32
Weerakiet et al GDM, PIH, preeclampsia, PTD 39 219 Spontaneous, ovulation Prospective
induction, ART
................................................................................................................................................................................................................................................................................................................................................................................
33
Sir-Peterman et al GDM, preeclampsia, PTD, LGA, SGA 47 180 Spontaneous, unspecified ART Prospective
................................................................................................................................................................................................................................................................................................................................................................................
34
Lesser and Garcia GDM 24 44 Unspecified ART Retrospective
................................................................................................................................................................................................................................................................................................................................................................................
35
Lo et al GDM 1542 84882 Not stated Retrospective
................................................................................................................................................................................................................................................................................................................................................................................
36
Sir-Peterman et al GDM, PIH 48 51 Not stated Prospective
................................................................................................................................................................................................................................................................................................................................................................................
ART, assisted reproductive technique; GDM, gestational diabetes mellitus; LGA, large-for-gestational age; NICU, neonatal intensive care unit; OVD, operative vaginal delivery; PIH, pregnancy-induced
hypertension; PTD, preterm delivery; SGA, small-for-gestational age.
Kjerulff. Pregnancy outcomes and polycystic ovary syndrome. Am J Obstet Gynecol 2011.

This information should encourage tients are screened for these complica- lence and management of pregnancy
practitioners to be vigilant when caring tions, solely based on PCOS diagnosis. complications. As suggested in the 2006
for women with PCOS. Currently, there In addition to establishing causation, AE-PCOS task force report, pheno-
is insufficient evidence to establish cau- we also must investigate how the pheno- typic groups may include (1) full-blown
sation and to support changing how pa- typic variants of PCOS alter the preva- PCOS (hyperandrogenemia, hirsutism,

558.e3 American Journal of Obstetrics & Gynecology JUNE 2011

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www.AJOG.org SAAOG Papers

TABLE 2
Summary of results
Group, n
Patients with polycystic Control patients with polycystic Odds ratio
Variable ovary syndrome Total ovary syndrome Total (95% CI)
Gestational diabetes mellitus 340 2385 5263 89,669 2.82 (1.93–4.10)
................................................................................................................................................................................................................................................................................................................................................................................
Pregnancy-induced hypertension 84 521 56 1317 4.07 (2.75–6.02)
................................................................................................................................................................................................................................................................................................................................................................................
Preeclampsia 63 589 57 2228 4.23 (2.77–6.46)
................................................................................................................................................................................................................................................................................................................................................................................
Preterm delivery 76 565 155 2129 2.20 (1.59–3.04)
................................................................................................................................................................................................................................................................................................................................................................................
Cesarean delivery 57 171 201 716 1.41 (0.96–2.07)
................................................................................................................................................................................................................................................................................................................................................................................
Operative vaginal delivery 43 160 62 583 1.56 (0.93–2.63)
................................................................................................................................................................................................................................................................................................................................................................................
Small-for-gestational age 29 204 16 353 2.62 (1.35–5.10
................................................................................................................................................................................................................................................................................................................................................................................
Large-for-gestational age 32 204 44 353 1.56 (0.92–2.64)
................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval.
Kjerulff. Pregnancy outcomes and polycystic ovary syndrome. Am J Obstet Gynecol 2011.

oligo-anovulation, and polycystic-ap-

TABLE 3 pearing ovaries), (2) hyperandrogenism
Odds ratio for incidence of gestation diabetes mellitus of women with menstrual irregularities, (3) and/or
with polycystic ovary syndrome and control patients hyperandrogenism without menstrual
irregularities. Palomba et al18 are to date
Group (n/N)
the only investigators that have pub-
Women with lished an assessment in this manner. In
polycystic ovary Control their prospective controlled study that
Study syndrome patients Odds ratio (95% CI)
compared 97 patients with PCOS with 73
Altieri et al14 3/15 6/159 6.38 (1.41–28.72) healthy pregnant subjects, they found an
..............................................................................................................................................................................................................................................
18
Palomba et al 15/93 4/69 3.13 (0.99–9.88)
..............................................................................................................................................................................................................................................
overall increased risk for adverse obstet-
Levran et al 20
15/76 9/95 2.35 (0.97–5.72) ric and neonatal outcome but noted that
..............................................................................................................................................................................................................................................
21 this risk varied according to the different
Wortsman et al 4/53 153/2306 1.15 (0.41–3.22)
..............................................................................................................................................................................................................................................
22
phenotypes. Specifically, the relative risk
Cardenas et al 1/31 1/78 2.57 (0.16–42.37) for adverse obstetric and neonatal out-
..............................................................................................................................................................................................................................................
23
Urman et al 6/47 2/100 7.17 (1.39–37.01) comes were 1.93 (95% CI, 1.12–2.96) for
..............................................................................................................................................................................................................................................
Fridstrom et al 24
1/33 1/66 2.03 (0.12–33.54) full-blown phenotype, 2.23 (95% CI,
..............................................................................................................................................................................................................................................
Radon et al 25
9/22 2/66 22.15 (4.28–114.68)
1.21–3.15) for hyperandrogenic non-
..............................................................................................................................................................................................................................................
27
PCO type, 0.54 (95% CI, 0.09 –1.63)
Vollenhoven et al 13/60 10/60 1.38 (0.55–3.45)
.............................................................................................................................................................................................................................................. for nonhyperandrogenic type, and 0.48
28
Mikola et al 20/99 66/737 2.57 (1.48–4.47) (95% CI, 0.31– 0.78) for ovulatory phe-
..............................................................................................................................................................................................................................................
Bjercke et al 29
4/52 2/355 14.71 (2.62–82.46) notypes. This suggested that patients
..............................................................................................................................................................................................................................................
Haakova et al 30
3/66 8/66 0.36 (0.087–1.36) with PCOS can be further categorized as
..............................................................................................................................................................................................................................................
31
high-risk if they have full-blown PCOS
Turhan et al 1/38 11/136 0.31 (0.038–2.46)
.............................................................................................................................................................................................................................................. or have non-PCO hyperandrogenic phe-
32
Weerakiet et al 8/39 13/219 4.09 (1.57–10.66) notypes.18 Specific risk assessment of
..............................................................................................................................................................................................................................................
33
Sir-Petermann et al 6/47 1/180 26.20 (3.07–223.54) each phenotypic group may help identify
..............................................................................................................................................................................................................................................
Lesser and Garcia 34
4/24 3/44 2.73 (0.56–13.40) patients with high-risk PCOS vs patients
..............................................................................................................................................................................................................................................
35 with low-risk PCOS to improve effi-
Lo et al 221/1542 4970/84,882 2.69 (2.33–3.11)
.............................................................................................................................................................................................................................................. ciency of screening, diagnosis, and
36
Sir-Petermann et al 6/48 1/51 7.14 (0.827–61.71) treatment.
..............................................................................................................................................................................................................................................
TOTAL 340/2385 5263/89,669 2.82 (1.94–4.11) Another classification of PCOS that is
..............................................................................................................................................................................................................................................
Heterogeneity ␹2 ⫽ 36.19 (degrees of freedom ⫽ 17; P ⫽ .004); estimate of between-study variance Tau-squared ⫽ described frequently is “lean” vs “obese”
0.2369; test of odds ratio ⫽ 1: z ⫽ 5.42; P ⫽ .000. patients with PCOS. The difference of
CI, confidence interval.
Kjerulff. Pregnancy outcomes and polycystic ovary syndrome. Am J Obstet Gynecol 2011.
weight and body mass index between
these 2 phenotypes may be the cause of

JUNE 2011 American Journal of Obstetrics & Gynecology 558.e4

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the marked heterogeneity that is noted

among the studies the have evaluated TABLE 4
gestational diabetes mellitus. A sub- Odds ratio for incidence of pregnancy-induced hypertension of women
group analysis that compared language with polycystic ovary syndrome and control patients
and date and country of publication did Group (n/N)
not explain the heterogeneity. We at-
Women with
tempted to investigate whether body polycystic ovary Control
mass index would account for this vari- Study syndrome patients Odds ratio (95% CI)
ation, but few studies included patient Altieriat et al14 2/15 10/159 2.29 (0.45–11.59)
..............................................................................................................................................................................................................................................
weight in their data, and even fewer stud- 15
Hu et al 6/22 0/22 17.73 (0.93–337.26)
ies documented body mass index. An in- ..............................................................................................................................................................................................................................................
18
depth metaregression that compared Palomba et al 13/93 3/69 3.58 (0.98–13.08)
..............................................................................................................................................................................................................................................
body mass index and age among women Urman et al 23
12/47 8/100 3.94 (1.49–10.46)
..............................................................................................................................................................................................................................................
with and without PCOS might illumi- Fridstrom et al 24
6/33 3/66 4.67 (1.09–20.04)
..............................................................................................................................................................................................................................................
nate reasons for variability between
Kashyap and 7/22 1/27 12.13 (1.36–108.36)
studies. Claman26
Last, we must examine how the use of ..............................................................................................................................................................................................................................................
27
metformin past the first trimester may Vollenhoven et al 10/44 3/44 4.02 (1.02–15.79)
..............................................................................................................................................................................................................................................
29
decrease pregnancy complications. It is Bjercke et al 6/52 1/355 46.17 (5.44–392.13)
..............................................................................................................................................................................................................................................
already known that PCOS increases the Haakova et al 30
5/66 4/66 1.27 (0.33–4.96)
..............................................................................................................................................................................................................................................
baseline insulin resistance of pregnancy. Turhan et al 31
4/38 9/136 1.66 (0.48–5.72)
Separately, metformin is known to de- ..............................................................................................................................................................................................................................................
32
crease this state of insulin resistance in Weerakiet et al 9/41 14/222 4.18 (1.67–10.45)
..............................................................................................................................................................................................................................................
33
patients with PCOS. Although the use of Sir-Petermann et al 4/48 0/51 10.42 (0.55–198.83)
..............................................................................................................................................................................................................................................
metformin alone or in combination with TOTAL 84/521 56/1317 4.07 (2.75–6.02)
..............................................................................................................................................................................................................................................
clomiphene has not been shown to im- Heterogeneity ␹2 ⫽ 12.64 (degrees of freedom ⫽ 11; P ⫽ 0.317); test of odds ratio ⫽ 1: z ⫽ 7.03; P ⫽ .000.
prove live birth rates, clinical pregnancy CI, confidence interval.
rates are improved when compared with Kjerulff. Pregnancy outcomes and polycystic ovary syndrome. Am J Obstet Gynecol 2011.
placebo.1 Currently, 3 controlled trials
and 3 observational studies have investi-
gated the prevention of gestational dia- TABLE 5
betes mellitus by continuing metfor- Odds ratio for the incidence of preeclampsia for women
min therapy throughout pregnancy in with polycystic ovary syndrome and control patients
women with PCOS, but the sample sizes Group (n/N)
are small, and the results are conflicting.
Polycystic ovary Control
An initial metaanalysis of the use of met- Study syndrome patients Odds ratio (95% CI)
formin throughout pregnancy was per- 14
Altieri et al 0/15 2/159 2.03 (0.09–44.26)
formed but did not show a statistically ..............................................................................................................................................................................................................................................
16
significant reduction of gestational dia- Li et al 6/34 4/70 3.54 (0.93–13.51)
..............................................................................................................................................................................................................................................
betes mellitus. Palomba et al 18
9/93 1/69 7.29 (0.90–58.94)
..............................................................................................................................................................................................................................................
Inherent to the nature of observa- Diamant et al 19
20/70 3/71 9.07 (2.55–32.20)
tional studies are the main limitations to ..............................................................................................................................................................................................................................................
23
Urman et al 3/47 4/100 1.64 (0.35–7.62)
this study: heterogeneity and lack of pro- ..............................................................................................................................................................................................................................................
24
spective data to establish causation. De- Fridstrom et al 3/33 0/66 15.26 (0.76–304.73)
..............................................................................................................................................................................................................................................
spite its limitation, this study is still Radon et al 25
5/22 1/66 19.12 (2.09–174.70)
..............................................................................................................................................................................................................................................
useful for clinical practice. Physicians Mikola et al 28
4/99 14/737 2.17 (0.70–6.74)
should continue to consider patients ..............................................................................................................................................................................................................................................
29
Bjercke et al 7/52 25/355 2.05 (0.84–5.02)
with PCOS to be high risk and to moni- ..............................................................................................................................................................................................................................................
31
tor them closely for the development of Turhan et al 3/38 2/136 5.74 (0.92–35.71)
..............................................................................................................................................................................................................................................
gestational diabetes mellitus, pregnancy- Weerakiet et al 32
1/39 1/219 5.74 (0.35–93.70)
..............................................................................................................................................................................................................................................
induced hypertension, and preeclamp- Sir-Petermann et al 33
2/47 0/180 19.84 (0.94–420.39)
sia. Hypertensive disorders in PCOS may ..............................................................................................................................................................................................................................................
TOTAL 63/589 57/2228 4.23 (2.77–6.46)
be due to low levels of insulin-like ..............................................................................................................................................................................................................................................

growth factor binding globulin-1 and Heterogeneity ␹2 ⫽ 10.87 (degrees of freedom ⫽ 11; P ⫽ .454); test of odds ratio ⫽ 1: z ⫽ 6.69; P ⫽ .000.
CI, confidence interval.
therefore may account for the increase in Kjerulff. Pregnancy outcomes and polycystic ovary syndrome. Am J Obstet Gynecol 2011.
pregnancy-induced hypertension and

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www.AJOG.org SAAOG Papers
ovary syndrome. J Reprod Med 1991;36:
TABLE 6 659-61.
Comparison of the odds ratios of the current and previous metaanalyses 22. Cardenas M, Coulson CC, Legro RS. Infer-
tile PCOS women do not have an increased risk
Odds ratio (95% CI) for gestational diabetes or macrosomia [ab-
stract]. Hum Reprod Update 2006;12:673-83.
Variable Current study (2010) Boomsma et al5 (2006)
23. Urman B, Sarac E, Dogan L, Gurgan T. Preg-
Pregnancy-induced hypertension 4.07 (2.75–6.02) 3.67 (1.98–6.81) nancy in infertile PCOD patients, complications
..............................................................................................................................................................................................................................................
and outcome. J Reprod Med 1997;42:501-5.
Preeclampsia 4.23 (2.77–6.46) 3.47 (1.95–6.17)
.............................................................................................................................................................................................................................................. 24. Fridstrom M, Nisell H, Sjoblom P, Hillensjo
Preterm delivery 2.20 (1.59–3.04) 1.75 (1.16–2.62) T. Are women with polycystic ovary syndrome
..............................................................................................................................................................................................................................................
at an increased risk of pregnancy-induced hy-
Small-for-gestational age 2.62 (1.35–5.10) 1.16 (0.31–5.12)
.............................................................................................................................................................................................................................................. pertension and/or preeclampsia? Hypertens
CI, confidence interval. Pregnancy 1999;18:73-80.
Kjerulff. Pregnancy outcomes and polycystic ovary syndrome. Am J Obstet Gynecol 2011. 25. Radon PA, McMahon MJ, Meyer WR. Im-
paired glucose tolerance in pregnant women
with polycystic ovary syndrome. Obstet Gyne-
preeclampsia in our study population. diabetes mellitus in women with polycystic col 1999;94:194-7.
ovary syndrome. J Perinat Med 2010 38:141-6. 26. Kashyap S, Claman P. Polycystic ovary dis-
Practitioners should wait for additional
11. Azziz R, Carmina E, Dewailly D, et al. The ease and the risk of pregnancy-induced hyper-
evidence that supports deviation from Androgen Excess and PCOS Society Criteria tension. J Reprod Med 2000;45:991-4.
current screening guidelines. f for the Polycystic Ovary Syndrome: the com- 27. Vollenhoven B, Clark S, Kovacs G, Burger
plete task force report. Fertil Steril 2009; H, Healy D. Prevalence of gestational diabetes
91:456-88. mellitus in polycystic ovarian syndrome (PCOS)
REFERENCES 12. Toulis KA, Goulis DG, Kolibianakis EM, et al. patients pregnant after ovulation induction with
1. Tang T, Lord JM, Norman RJ, Yasmin E, Risk of gestational diabetes mellitus in women gonadotrophins. Aust N Z J Obstet Gynaecol
Balen AH. Insulin-sensitizing drugs (metformin, with polycystic ovary syndrome: a systematic 2000;40:54-8.
rosiglitazone, pioglitazone, D-chiro-inositol) for review and a meta-analysis. Fertil Steril 2009; 28. Mikola M, Hiilesmaa V, Halttunen M,
women with polycystic ovary syndrome, oligo 92:667-77. Suhonen L, Tiitinen A. Obstetric outcome in
amenorrhea and subfertility. Cochrane Data- 13. Stroup DF, Berlin JA, Morton SC, et al. women with polycystic ovarian syndrome. Hum
base Syst Rev 2009:CD003053. Meta-analysis of observational studies in epide- Reprod 2001;16:226-9.
2. American College of Obstetricians and Gyne- miology: a proposal for reporting: Meta-analysis 29. Bjercke S, Dale PO, Tanbo T, Storeng R,
cologists. ACOG practice bulletin no. 108: poly- of Observational Studies in Epidemiology Ertzeid G, Abyholm T. Impact of insulin resistance
cystic ovary syndrome. Obstet Gynecol 2009; (MOOSE) group. JAMA 2000;283:2008-12. on pregnancy complications and outcome in
114:936-49. 14. Altieri P, Gambineri A, Prontera O, et al. Ma- women with polycystic ovary syndrome. Gynecol
3. Azziz R, Ehrmann D, Legro RS, et al. Trogli- ternal polycystic ovary syndrome may be asso- Obstet Invest 2002;54:94-8.
tazone improves ovulation and hirsutism in the ciated with adverse pregnancy outcomes. Eur J 30. Haakova L, Cibula D, Rezabek K, Hill M, Fanta
polycystic ovary syndrome: a multicenter, dou- Obstet Gynecol Reprod Biol 2010;149:31-6. M, Zivny J. Pregnancy outcome in women with
ble-blond, placebo-controlled trial. PCOS/Tro- 15. Hu S, Lenoard A, Seifalian A, Hardiman P. PCOS and in controls matched by age and
glitazone study group. J Clin Endocrinol Metab Vascular dysfunction during pregnancy in weight. Hum Reprod 2003;18:1438-41.
2001;86:1626-32. women with polycystic ovary syndrome. Hum 31. Turhan NO, Seçkin NC, Aybar F, Inegöl I.
4. Lord JM, Flight IH, Norman RJ. Metformin in Reprod 2007;22:1532-9. Assessment of glucose tolerance and preg-
polycystic ovary syndrome: systematic review 16. Li G, Fan L, Zhang L, Zhang W, Huang X. nancy outcome of polycystic ovary patients. Int
and meta-analysis BMJ 2003;327:951-3. Metabolic parameters and perinatal outcomes J Gynaecol Obstet 2003;81:163-8.
5. Heijnen E, Eijkemans M, Hughes E, Laven J, of gestational diabetes in women with polycys- 32. Weerakiet S, Srisombut C, Rojanasakul A,
Macklon N, Fauser B. A meta-analysis of out- tic ovary syndrome. J Perinat Med 2010;38: Panburana P, Thakkinstian A, Herabutya Y.
comes of conventional IVF in women with poly- 141-6. Prevalence of gestational diabetes mellitus and
cystic ovary syndrome. Hum Reprod Update 17. Maliqueo M, Echiburú B, Crisosto N, et al. pregnancy outcomes in Asian women with
2006;12:13-21. Metabolic parameters in cord blood of new- polycystic ovary syndrome. Gynecol Endocrinol
6. Yogev Y, Ben-Haroush A, Chen R, et al. Di- borns of women with polycystic ovary syn- 2004;19:134-40.
urnal glycemic profile in obese and normal drome. Fertil Steril 2009;92:277-82. 33. Sir-Petermann T, Hitchsfeld C, Maliqueo M,
weight nondiabetic pregnant women. Am J Ob- 18. Palomba S, Falbo A, Russo T, Tolino A, Orio et al. Birth weight in offspring of mothers with
stet Gynecol 2004;191:949. F, Zullo F. Pregnancy in women with polycystic polycystic ovarian syndrome. Hum Reprod
7. Ryan E. Hormones and insulin resistance in ovary syndrome: the effect of different pheno- 2005;20:2122-6.
pregnancy. Lancet 2003;362:1777. types and features on obstetric and neonatal 34. Lesser KB, Garcia FA. Association between
8. Jensen RB, Chellakooty M, Vielwerth S, et al. outcomes. Fertil Steril 2010;94:1805-11. polycystic ovary syndrome and glucose intoler-
Intrauterine growth retardation and conse- 19. Diamant YZ, Rimon E, Evron S. High inci- ance during pregnancy. J Matern Fetal Med
quences for endocrine and cardiovascular dis- dence of preeclamptic toxemia in patients with 1997;6:303-7.
ease in adult life: does insulin-like growth fac- polycystic ovarian disease. Eur J Obstet Gyne- 35. Lo JC, Feigenbaum SL, Yang J, Pressman
tor-1 play a role? Horm Res 2003;60(suppl): col Reprod Biol 1982;14:199-204. AR, Selby JV, Go A. Epidemiology and adverse
136-48. 20. Levran JS, Imani B, Eijkemans MJ, Fauser cardiovascular risk profile of diagnosed poly-
9. Boomsma CM, Eijkemans MJC, Huges EG, BC. New approach to polycystic ovary syn- cystic ovary syndrome. J Clin Endocrinol Metab
et al. A meta-analysis of pregnancy outcomes in drome and other forms of anovulatory infertility 2006;91:1357-63.
women with polycystic ovary syndrome. Hum Obstet Gynecol Surv 2002;57:755– 67. 36. Sir-Petermann T, Echiburú B, Maliqueo MM,
Reprod Update 2006;12:673-83. 21. Wortsman J, de Angeles S, Futterweit W, et al. Serum adiponectin and lipid concentrations
10. Li G, Fan L, Zhang L, et al. Metabolic pa- Singh KB, Kaufmann RC. Gestational diabetes in pregnant women with polycystic ovary syn-
rameters and perinatal outcomes of gestational and neonatal macrosomia in the polycystic drome. Hum Reprod 2007;22:1830-6.

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