Format for Mini-CAT

Clinical Question: Please state this as briefly as possible based on the scenario provided

23 y/o pregnant F with a PMH of PCOS presents to the gynecologist worried that she will have adverse obstetric outcomes including maternal and neonatal complications.

Do women with PCOS have increased adverse obstetric outcomes?

PICO Question:

Identify the PICO elements (Recalling that some questions do not have all the elements)

P – Adult, pre-menopausal females  

I – women with PCOS

C – women without PCOS

O – adverse obstetric outcomes  

Search Strategy:

Outline the terms used, databases  or other tools used, how many articles returned, and how  you selected the final articles to base your CAT on

P	I	C	O
Adult females	PCOS	No PCOS	Adverse obstetric outcome
Pre-menopausal women	Polycystic Ovarian Syndrome		Maternal complications
Pregnant women	Polycystic Ovary Disease		Fetal/Neonatal complications

Databases: PubMed, Google Scholar, Science Direct

Terms Used: PCOS and increased risk of adverse obstetric outcomes, pregnant women with PCOS and maternal complications, PCOS and pregnancy complications, PCOS and adverse neonatal complications

Articles Returned:

• PubMed: +last 7 years = 419
• Google Scholar: +last 5 years =  9,200
• Science Direct: +last 5 years = 379

Articles Chosen for Inclusion (please copy and paste the abstract with link):

1. Pregnancy complications in women with polycystic ovary syndrome

This article shows the relationship between PCOS and negative pregnancy outcomes through both systematic reviews with meta-analysis and randomized controlled trials. The most recent meta-analysis published in 2013 includes 4 studies involving 4,982 women with PCOS and 119,692 controls and all indicate that women with PCOS experience greater pregnancy complications along with maternal and neonatal complications than women without PCOS.

https://academic-oup-com.york.ezproxy.cuny.edu/humupd/article/21/5/575/566450

• Association between polycystic ovary syndrome and the risk of pregnancy complications

This article contains a large comprehensive quantitative study based on 40 observational studies reporting data on 17,816 pregnancies with PCOS and 123,756 pregnancies without PCOS. PCOS pregnancies were found to have a greater risk of GDM (gestational diabetes mellitus), preeclampsia, preterm delivery, cesarean delivery, miscarriage and perinatal death.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5181798/

• Obstetric complications in women with polycystic ovary syndrome: a systematic review and meta-analysis

A systematic review and meta-analysis on obstetric complications in women with PCOS. This article explains a systematic literature review looking at the rates of the pregnancy complications (listed above) including the admission rates to the NICU (neonatal intensive care unit) in women with PCOS. Sensitivity analyses were performed to ensure reliability and validity of results. 27 studies done involving 4982 women with PCOS and 119,692 controls or women without PCOS for the meta-analysis. Women with PCOS showed increased risk of adverse pregnancy and neonatal complications.

https://www-ncbi-nlm-nih-gov.york.ezproxy.cuny.edu/pmc/articles/PMC3737012/

• Increased rates of complications in singleton pregnancies of women previously diagnosed with polycystic ovary syndrome predominantly in the hyperandrogenic phenotype

This article studies the relationship between maternal and neonatal complications in a cohort of women with hyperandrogenic and normo-androgenic PCOS using a prospective cohort study. 188 women with PCOS and singleton pregnancies along with 2,889 women with a naturally conceived singleton pregnancy. Results showed that women with PCOS had a statistically significant greater risk of developing the maternal complication gestational diabetes. More specifically, the maternal complications, not neonatal complications, were more significant in women with hyperandrogenic PCOS compared with those with normoandrogenic PCOS. (women with PCOS have inc risk of maternal complications esp those with hyperandrogenic phenotype).

https://www-sciencedirect-com.york.ezproxy.cuny.edu/science/article/abs/pii/S0015028217304399

• Generational Health Impact of PCOS on Women and Their Children

This article describes the review of observational studies of 17,186 pregnant women with PCOS compared to 124,000 pregnant women without PCOS, including young and lean women with PCOS. Average age of women included was under 33 years old and the average BMI was less than 29 kg/m2 with the majority around 22-27. Results showed that pregnant women with PCOS were at an increased chance of complications with gestational diabetes almost threefold, pre-eclampsia almost threefold and 50% increased risk of preterm delivery. Overall the results showed a transgenerational health influence of maternal PCOS imparted to the offspring along with actual maternal complications by itself.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6473601/

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
2015		Meta-analysis & Randomized Controlled Trials (RCT) – 4,982 women with PCOS & 119,692 controls	Pregnancy complications along with maternal & neonatal complications (focused on pathophys regarding PCOS & complications, intervention, prevention & management)	Women with PCOS experience greater complications than women without PCOS	Limited available data suggest that offspring of women with PCOS have inc risk for future metabolic & reproductive dysfunction
2016		Comprehensive quantitative study based on 40 observational studies reporting data on 17,816 PCOS pregnancies & 123,756 non-PCOS pregnancies.	If there will be greater obstetric complications in a PCOS pregnancy vs a non-PCOS pregnancy	PCOS pregnancies were found to have a greater risk of GDM (gestational diabetes mellitus), preeclampsia, preterm delivery, cesarean delivery, miscarriage & perinatal death	Inherent limit of the study was that most fetal and neonatal outcomes could not be assessed AND adverse pregnancy, fetal and neonatal outcomes may differ acc. to factors such as study design, mean age and pre-BMI along with presence of PCOS.
2013		Systematic review & meta-analysis based on 27 studies done involving 4,982 women with PCOS & 119,692 controls (women without PCOS)	Adverse pregnancy outcomes in women with PCOS vs women without PCOS (focused on birth weight, caesarean section rate, premature delivery rate & admission to NICU) = specifically neonatal outcomes as opposed to maternal complications	Women with PCOS show increased risk of adverse pregnancy and neonatal complications than women without PCOS	Insufficient evidence to establish the real cause of adverse pregnancy & neonatal complications among women with PCOS and fail to provide independent risk factor for indicating effect on chance of developing such adverse complications.
2017		Prospective cohort study – 188 women with PCOS and singleton pregnancies & 2,889 women with a naturally conceived singleton pregnancy.	Studying the relationship between maternal & neonatal complications in a cohort of women with hyperandrogenic and normo-androgenic PCOS	Women with PCOS had significantly greater risk of developing maternal complication of gestational diabetes AND even more significant in hyperandrogenic PCOS compared to normo-androgenic PCOS	Setting was in the hospital and midwifery practices so maybe done in more settings would be more accurate (didn’t state its own limitation/biases)
2019		Review of observational studies of 17,186 pregnant women with PCOS & 124,000 pregnant women without PCOS including young and lean women with PCOS.	Studying increase risk of pregnancy complications in women with PCOS vs women without PCOS. These women with avg age of 33 and avg BMI less than 29 (majority around 22-27)	Pregnant women with PCOS have inc chance of complications with gestational diabetes almost threefold, pre-eclampsia almost threefold and 50% inc risk of preterm delivery. Overall – transgenerational health influence of maternal PCOS imparted to offspring along with maternal complications	While it was found that there is a clear transgenerational health influence of PCOS imparted to offspring, it is unclear which/any intervention and prevention will lead to long-term improvements in the health of the offspring.

Conclusion(s):

It was found that women with PCOS have an increased risk of adverse obstetric outcomes including maternal and neonatal complications. Complications such as gestational diabetes mellitus (GDM) and pre-eclampsia were found to be of the most common. Additionally, it was found that women with hyperandrogenic PCOS experienced more significant complications and adverse pregnancy outcomes.

Clinical Bottom Line: Women with PCOS have an increased risk of adverse obstetric outcomes and so further investigation is necessary into the importance of lifestyle modification, glucose control, hormonal regulation and medical therapy among women with PCOS during pregnancy to prevent complications.