If you skipped the last chapter because you’re already pregnant, congratulations! The best way to ensure you have a healthy baby—and you can!—is to look after you own body. In my role as a doctor, I have to recommend all the precautions you need to take and warn of the dangers, but don’t let these precautions overwhelm you. Don’t worry. Motherhood conquers all.
When women with PCOS become pregnant, they need to be more alert than healthy women for possible complications. All pregnant women, particularly those with PCOS, need to be tested for under- or overactive thyroid glands before and after they are pregnant, because they’re common and because they can cause powerful hormone imbalances. Some women with PCOS may already have type 2 diabetes, and many are vulnerable to gestational diabetes. In this chapter we’ll look at how these two kinds of diabetes can affect pregnancy. High blood pressure is a frequent health problem of women with PCOS and poses additional challenges during pregnancy. It’s well known that women with PCOS have a higher miscarriage rate, particularly during the early months of pregnancy, than healthy women. Therefore, we’ll also discuss taking metformin as a preventive measure against miscarriages. Finally, we look at the possible effects of a mother’s high male hormone level on her female fetus.
The thyroid gland is involved in virtually every body function, and very noticeably in those associated with weight and energy level. Thyroid function lab tests are important for all women, and particularly for pregnant women with PCOS. Once pregnant, you should contact your endocrinologist or obstetrician to schedule thyroid function tests. I perform these tests every three months during a pregnancy.
If an underactive thyroid (hypothyroidism) is not treated during early pregnancy, the fetus may develop neurological abnormalities of the brain. An underactive thyroid may also be responsible for other abnormalities and later cognitive problems. An increase in the blood level of the thyroid-stimulating hormone (TSH) occurs frequently during the first trimester of pregnancy, and you may need to begin taking a thyroid replacement drug.
An overactive thyroid gland (hyperthyroidism) also requires careful follow-up by your endocrinologist, who should prescribe the lowest effective dosage of antithyroid medication. You’ll need less of this medication in the third trimester, and lab tests can tell your doctor exactly how much less. Most women with overactive thyroids don’t require antithyroid medication at all.
Alert your pediatrician if you are taking thyroid replacement or antithyroid drugs.
Blood sugar flows freely to the fetus through the placenta, but insulin doesn’t. Thus a high maternal blood sugar level triggers a matching insulin response from the developing baby’s pancreas, which causes fetal weight gain (macrosomia). Mom’s increased blood sugar can also cause anomalies early in pregnancy and even miscarriage. These can all be prevented by tight control of blood sugar levels before and after you conceive. The risk of anomalies increases in the weeks before you give birth, so many medical centers will recommend induced delivery at thirty-eight weeks. With the advent of tight blood sugar control, more and more diabetic women are successfully giving birth to healthy babies.
Many women with PCOS are treated before pregnancy with the insulin-sensitizing medication metformin and other drugs for type 2 diabetes. While there is no evidence that metformin given during pregnancy harms the fetus, it does cross the placenta. Women with PCOS generally have increased insulin resistance during pregnancy, and unfortunately metformin is often not enough to maintain tight blood sugar control in type 2 diabetes. You may need to use insulin therapy, which has been shown to reduce fetal mortality by almost 80 percent in women with type 2 diabetes who do not have PCOS.
While the details of insulin therapy during pregnancy for women with type 2 diabetes are beyond the scope of this book, the following are important goals for pregnant women who have PCOS and either impaired glucose tolerance or type 2 diabetes.
• Very tight blood sugar control and meticulous management are vital, especially before conception and during the first seven weeks of pregnancy, when organ development of the fetus takes place.
• The one-hour postprandial blood glucose level should not exceed 120 mg/dL during pregnancy. The risk of weight gain by the fetus increases at levels above 120 mg/dL. Specialists have shown that for women with significant insulin resistance, as in PCOS, a one-hour postprandial blood glucose level not exceeding 110 mg/dL could further reduce potential risks.
• Your blood glucose level in the fasting state should be below 90 mg/dL. You should do numerous daily finger sticks with an accurate home monitor to follow your blood glucose levels.
• Maintain an HbAlc of 5 percent. Your average blood glucose level over ten to twelve weeks is called the glycosylated hemoglobin Alc (HbAlc). The HbAlc of normal pregnant women drops by 20 percent, to 5 percent or less. With PCOS, the 5 percent range is the target you should aim for. If you find this difficult to achieve, you may need to be referred to a diabetologist or an obstetrician familiar with diabetes during pregnancy.
• If you have retinal problems due to diabetes, have an ophthalmologist check your eyes before conception and follow up during pregnancy. Laser photocoagulation may be necessary before becoming pregnant.
Close teamwork of your obstetrician, endocrinologist, and diabetologist is a winning strategy for a healthy pregnancy and to keep the risks to you and the fetus to a minimum.
Some women develop high blood sugar levels during pregnancy, a condition known as gestational diabetes. This kind of diabetes typically occurs during the last half of pregnancy, and this is the time when insulin resistance is at its worst. Gestational diabetes usually disappears after pregnancy, but the chances are good that you will develop it again in future pregnancies.
Gestational diabetes occurs in 3 to 5 percent of pregnant women without known PCOS. Most studies show an increased incidence of gestational diabetes in women with PCOS; a few studies put the number at an incredible 40 percent. Estimates vary widely, though, and no large studies have been done to confirm the high end of the range.
It’s no surprise that women with PCOS run a greater risk of developing gestational diabetes. In normal women, pregnancy typically increases blood insulin levels anywhere from two and a half to three times. In women with PCOS, that increase comes on top of established insulin resistance, so that the insulin resistance may be increased sevenfold. The insulin-secreting beta cells of the pancreas often simply cannot keep up. Obesity only serves to fuel the insulin resistance fire during pregnancy, and this worsens as pregnancy advances.
The following risk factors for gestational diabetes apply to all pregnant women, with or without PCOS.
• Age greater than thirty
• Insulin resistance prior to pregnancy
• Obesity
• Prior gestational diabetes
• High birth weight of previous child
• Family history of type 2 diabetes
• Smoker
• Native American, African American, Hispanic American, Asian American, or Pacific Islander ethnicity
For some women, gestational diabetes is a first sign of approaching type 2 diabetes. Some specialists claim that one out of every two non-PCOS women develop type 2 diabetes within five years of having had gestational diabetes.
Effective treatment. Since gestational diabetes potentially harms both you and your baby, it’s important to start treatment promptly. Treatment may include frequent blood sugar monitoring, insulin injections, special meal plans, and regular physical activity. Your target range for a fasting glucose level should be 60 to 90 mg/L. I always recommend getting the support of a qualified nutritionist and diabetologist or endocrinologist, with experience in treating gestational diabetes.
In a recent study, women with PCOS who took metformin before conception and during pregnancy reduced the rate of gestational diabetes to 7 percent. During pregnancy, metformin reduces insulin resistance, testosterone level, and weight, significantly reducing the complications of gestational diabetes.
For more information on treatment and self-management, see the Web site addresses under Diabetes in the Resources section at the back of the book.
High blood pressure (hypertension) is one of the most common medical complications of pregnancy affecting both mother and fetus. Most studies show that pregnant women with PCOS are more likely than normal pregnant women to suffer from high blood pressure, and that those who are obese are at even higher risk. There are four different kinds of high blood pressure diagnoses: chronic hypertension, pre-eclampsia and eclampsia, chronic hypertension with superimposed pre-eclampsia, and gestational hypertension.
Women with chronic hypertension have had an ongoing high blood pressure problem before becoming pregnant. Like many people with high blood pressure, they may not have been aware of it. Many first learn of their condition when searching for help for PCOS, others during a pregnancy checkup.
Pre-eclampsia and eclampsia. Pre-eclampsia consists of a dangerous rise in blood pressure, swelling of the legs, and the presence of protein in the urine. Some 5 to 8 percent of all pregnant women suffer from this condition, which often begins during week 20 of pregnancy. Delivery may be induced prematurely when the mother’s health is at serious risk. Pre-eclampsia can cause seizures (eclampsia), kidney and liver damage, internal bleeding, and poor growth or death of the fetus. Your doctor should check your blood pressure and urine protein on all prenatal visits. If you do develop pre-eclampsia, you may be prescribed bedrest under managed care until the week 36 of your pregnancy, when the baby is ready for delivery.
The symptoms of pre-eclampsia and eclampsia include:
• Localized facial swelling of the face or hands
• A weight gain of two or more pounds a week that occurs unintentionally
• Headaches
• Nausea, vomiting
• Reduced urine production and the presence of protein in the urine
• High blood pressure
• A feeling of being agitated and occasional chest or abdominal pains
The risk of pre-eclampsia and eclampsia is three to four times higher in diabetic women, and this risk is significantly enhanced by poor diabetic control in the first four months of pregnancy. Risk factors for pre-eclampsia include the following—the first three put women with PCOS at particular risk.
• High blood pressure before pregnancy
• Type 2 diabetes before pregnancy
• African-American women
• Obesity before pregnancy
• Twins or triplets
• Pregnancy before age twenty
• Kidney disease, rheumatoid arthritis, lupus, scleroderma
If you have any of these risk factors, talk to your doctor— preferably before you become pregnant. Lowering your high blood pressure is probably the most important preventive step you can take.
Becoming pregnant late in life and having twins or triplets, after help from a fertility clinic, are a combination of risk factors responsible for increasing numbers of pre-eclampsia cases.
Chronic hypertension with superimposed pre-eclampsia. This third type of high blood pressure in pregnant women is more likely to develop when high blood pressure occurs early in pregnancy and worsens as it progresses. Unfortunately, this condition may lead to the placenta separating from the lining of the uterus before the usual time, causing pain, bleeding, and all too often miscarriage, though caesarean delivery can sometimes save the baby.
Gestational hypertension. In this condition, high blood pressure develops about halfway through pregnancy, but no proteins are excreted in the urine. Blood pressure usually returns to normal two to three months after delivery. Women with PCOS have a 12 percent incidence rate of pregnancy-induced hypertension compared with a 1.3 percent rate for normal women.
Treatment. You can lower your high blood pressure by losing 10 percent of your body weight, avoiding salt, and exercising regularly. Keep in mind that most doctors advise against taking ACE inhibitors and most other drugs for high blood pressure while you are pregnant.
Sadly, women with PCOS have three times the normal risk for early miscarriage, which is 10 to 15 percent in normal women. Of women who repeatedly miscarry in the first trimester, up to four out of five have been reported to have PCOS. There is hope for these women, though, in the form of the insulin-sensitizing medication metformin.
Metformin is recognized by the FDA as a Category B drug, which means that it has caused no fetal abnormalities in animal studies. Treatment with metformin often enables women with PCOS infertility to conceive, as we discussed in the previous chapter, and continued use during the first trimester may significantly reduce the chance of an early miscarriage. In one study, women with PCOS who continued metformin for the first trimester had a normal miscarriage rate (8.8 percent), while similar women who did not take metformin had a 42 percent miscarriage rate.
Metformin decreases high insulin levels, high male hormone levels, and possibly obesity. It reduces blood clotting and increases the levels of two protective proteins in the uterus lining.
Women with PCOS who have had three or more miscarriages have given birth after treatment with metformin for the first three months of pregnancy, and occasionally throughout pregnancy. Although metformin is not known to cause any fetal or birth defects, doctors must still hesitate to recommend this extended usage until more long-range studies show that it’s safe.
I recommend that a woman with PCOS who has not been pregnant before discontinue metformin when she conceives. If she has already had one or more miscarriages, she should have the option of continuing metformin for the first trimester. However, a large randomized clinical trial of women is necessary to establish that this is the best option for these women.