Pregnancy in women with PCOS

17 01 2011

To the Editor:

I read the article of Palomba et al (1) with great interest. This is the first study that investigates the pregnancy outcomes according to different phenotypes of polycystic ovary syndrome. They conclude that “The increased risk for adverse obstetric or neonatal outcomes, which are observed in women with PCOS, varies widely according to their different PCOS phenotypes and features.” Although it is clear that the results are attractive, some of the data in this paper need further clarification.

As illustrated in Table 4, this study consists of 93 polycystic ovary syndrome (PCOS) patients (14 full-blown, 7 non-PCO, 5 non-hyperandrogenic and 63 ovulatory). As I can understand from Table 4, in the group of 14 patients with full-blown features of PCOS, 9 pregnancies ended with miscarriage (this means 64.3 % miscarriage rate in this category). In the remaining 5 patients, GDM and PIH occurred concomitantly and PE occurred in 4 patients. It means that all the patients demonstrated one of the complications of pregnancy (100%). Although it is a very high complication rate, one can assume that this could be attributed to the low number of cases in this study. But the other parameters in this category are confusing. Antepartum hemorrhage occurred 9/14 patients, SGA in 6/14, LGA in 3/14, APA in 6/14 (this means there is 15 babies), operative delivery in 12/14 patients. How are these numbers possible in the 5 remaining patients? The numbers in the other categories are also confusing. While it is possible to make mistakes in tables, if the mistakes affect the conclusions of the study, these confusing data must be clarified.

I appreciate the authors’ hypothesis and their 5-year effort on this study, but with the small number of patients (especially in subgroups), it is impossible to draw solid conclusions regarding the relationship between pregnancy complications and the different phenotypes of PCOS.

Tayfun Bagis, M.D.
Division of Reproductive and Endocrinology Unit
Department of Obstetrics and Gynecol
Faculty of Medicine
Baskent University
Adana, Turkey

Reference
1. Palomba S, Falbo A, Russo T, Tolino A, Orio F, Zullo F. Pregnancy in women with polycystic ovary syndrome: the effect of different phenotypes and features on obstetric and neonatal outcomes. Fertil Steril 2010;94:1805-11.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.01.144

The Authors Respond:

We thank Dr. Bagis for his interest and comments regarding our manuscript recently published in Fertility and Sterility (1).

He remarked the high pregnancy complication rate of patients belonged to the full-blown polycystic ovary syndrome (PCOS) phenotype. In particular, in this sub-group, miscarriages occurred in 64.3% of patients, whereas pregnancy induced hypertension (PIH), pre-eclampsia (PE) and gestational diabetes mellitus (GDM) concomitantly occurred in 35.7%, 28.6% and 35.7% of cases, respectively. Considering subjects having a miscarriage, these percentages were very high. Furthermore, they were very similar to those reported by other authors in a more heterogeneous PCOS population (2).

In addition, we reported an antepartum hemorrhage in 64.3% of cases considering any vaginal bleeding similar to menstrual loss before delivery; obviously we also included patients who successively had a miscarriage. Indeed, complications observed in the sub-group of patients with full-blown phenotype was very high, but we can assume that this could be due to the low number of cases included.

In addition, thanks to Dr. Bagis’ observation, we had the opportunity to detect some slight mistakes in the presentation and analysis of our data, in particular with regard to the distribution of fetal growth and the operative delivery rate. In this regard, and in agreement with Bagis’ comment, we revised our tabulated data and found that small gestational age (SGA) occurred in 3 out of 5 (60%), 2 out of 3 (66.7%), 0 out of 2 (0%) and 10 out of 60 (16.7%) of the full-blown, non-polycystic ovary (PCO), non-hyperandrogenic and ovulatory phenotypes, respectively. Large for gestational age (LGA) occurred in 1 out of 5 (20%), 0 out of 3 (0%), 0 out of 2 (0%) and 4 out of 60 (6.7%) of the full-blown, non-PCO, non-hyperandrogenic and ovulatory phenotypes, respectively. Appropriate for gestational age (AGA) occurred in 1 out of 5 (20%), 1 out of 3 (33.3%), 2 out of 2 (100%) and 50 out of 60 (83.3%) of the full-blown, non-PCO, non-hyperandrogenic and ovulatory phenotypes, respectively.

On the other hand, the operative delivery rate was 3 out of 5 (60%), 2 out of 3 (66.7%), 1 out of 2 (50%) and 10 out of 60 (16.7%) of the full-blown, non-PCO, non-hyperandrogenic and ovulatory phenotypes, respectively.

Despite these incongruities with the original paper, the statistical significance of our results remained totally unchanged.

Finally, we agree with Dr. Bagis regarding the small number of patients (especially after subgroup analysis) that make it impossible to draw solid conclusions regarding the relationship between pregnancy complications in PCOS and the different PCOS phenotypes. Moreover, our final conclusions seem to be appropriate. In fact, we highlighted that further studies on a bigger sample population are needed to confirm the current findings, particularly with respect to the rarer phenotypes. In this regard, considering the long time requird to enroll and follow-up with our well selected sample, we suggest an international registry should be instituted to report the incidence of obstetrical complications in PCOS women and to obtain larger sub-groups of PCOS phenotypes.

Stefano Palomba, M.D.a
Angela Falbo, M.D.a
Tiziana Russo, M.D.a
Achille Tolino, M.D.b
Francesco Orio, M.D.c
Fulvio Zullo, M.D.a

aDepartments of Obstetrics and Gynecology
University ‘‘Magna Graecia’’ of Catanzaro
Catanzaro, Italy
b University ‘‘Federico II’’ of Naples
Naples, Italy
c Department of Endocrinology
University ‘‘Parthenope’’ of Naples
Naples, Italy

References
1. Palomba S, Falbo A, Russo T, Tolino A, Orio F, Zullo F. Pregnancy in women with polycystic ovary syndrome: the effect of different phenotypes and features on obstetric and neonatal outcomes. Fertil Steril 2010;94:1805-11.

2. Boomsma CM, Eijkemans MJ, Hughes EG, Visser GH, Fauser BC, Macklon NS. A meta-analysis of pregnancy outcomes in women with polycystic ovary syndrome. Hum Reprod Update 2006;12:673-83.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.01.145

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