Polycystic ovary syndrome (PCOS) affects approximately 13% of women of reproductive age globally, impacting an estimated 17 million pregnancies annually. Among the most clinically significant pregnancy complications associated with PCOS is gestational diabetes mellitus (GDM), with women with PCOS facing a 2 to 3-fold higher odds of developing GDM compared with women without PCOS, independent of age, BMI, and mode of conception.
This presentation draws on two large systematic reviews and meta-analyses, comprising 104 studies and over 106,000 pregnancies, which informed the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. These analyses confirm that the elevated risk of GDM in PCOS persists across prospective and high-quality studies, in both spontaneous and assisted reproductive technology (ART) pregnancies, and in women matched for age and BMI, underscoring that intrinsic PCOS pathophysiology, including insulin resistance and chronic low-grade inflammation, drives this risk beyond shared metabolic risk factors.
The compounding nature of GDM in PCOS is profound. Women with PCOS and GDM face further elevated odds of gestational hypertension, pre-eclampsia, and cesarean section, while their offspring are at increased risk of preterm birth, fetal growth restriction, and low birthweight. Critically, the overall magnitude of adverse pregnancy risk in PCOS is comparable to that seen in pregnancies affected by type 1 diabetes, a population universally recognised as high-risk and systematically monitored. Yet recognition of PCOS as a risk factor for GDM and broader pregnancy complications remains strikingly low among both patients and health professionals, representing a significant missed opportunity for prevention and early intervention.
This under-recognition is not incidental. A large international longitudinal survey across six continents, engaging over 7,700 patients and health professionals, found that recognition of pregnancy complications as a feature of PCOS was limited in 2015, and while awareness improved significantly by 2023 following two International Guidelines and extensive advocacy efforts, gaps persist, with over 20% of patients and health professionals still not recognising the association between PCOS and pregnancy complications including GDM. The same body of work identified that the name "polycystic ovary syndrome" itself is a structural barrier, perceived as misleading and ovary-focused, that has contributed to inadequate research funding, educational gaps, and underrecognition of PCOS as the metabolic and endocrine condition it is, with GDM being a prime example of a risk that falls through the cracks of a gynaecologically-framed condition.
The 2023 International PCOS Guideline recommends that PCOS status be identified at preconception or at the first antenatal visit, and that all women with PCOS be offered an oral glucose tolerance test (OGTT) early in pregnancy, if not performed preconceptionally, repeated at 24 to 28 weeks' gestation. Monitoring of blood pressure, gestational weight gain, and fetal growth are also strongly recommended. This presentation will explore the evidence underpinning these recommendations, the pathophysiological links between PCOS and GDM, the implications for maternal and offspring outcomes, and the practical opportunities for clinicians to improve identification, monitoring, and early intervention in this high-risk and underserved population.