Polycystic ovary syndrome (PCOS) is among the most frequent endocrine disorders in women of reproductive age, affecting between 8–13% worldwide, though actual figures vary depending on the diagnostic criteria applied and the population studied [1,2]. It is defined by the Rotterdam consensus [3] as the presence of at least two of the following: ovulatory dysfunction, hyperandrogenism, and polycystic ovarian morphology on ultrasound. While traditionally considered a gynecological condition, PCOS is now recognized as a systemic disorder that overlaps with metabolic syndrome, insulin resistance, obesity, and an increased lifetime risk of type 2 diabetes and cardiovascular disease [4]. The prevalence of PCOS in South Asia has increased steadily over the past two decades, likely reflecting lifestyle changes, dietary shifts, and urbanization [5]. Indian data suggest that nearly one in five young women may be affected [6]. However, diagnosis is often delayed, with many women first presenting during evaluations for infertility. The implications of PCOS extend beyond fertility issues, as women are also at risk for complications during pregnancy such as miscarriage, gestational diabetes mellitus (GDM), hypertensive disorders, and preterm delivery [7–9]. These outcomes are mediated by a combination of hormonal, metabolic, and vascular mechanisms, including hyperinsulinemia, hyperandrogenism, endothelial dysfunction, and impaired endometrial receptivity [10,11]. In low- and middle-income settings such as India, these complications carry additional significance. Women may have limited access to specialized care, and neonatal intensive care resources are unevenly distributed. Consequently, adverse pregnancy outcomes such as preterm birth and intrauterine growth restriction have higher morbidity implications compared to high-income countries [12]. Cesarean section rates in PCOS are also elevated, influenced both by maternal complications and obstetric interventions [13]. In addition to obstetric risks, women with PCOS experience gynecological concerns including infertility, menstrual irregularities, and a heightened risk of endometrial hyperplasia and carcinoma [14]. Given this overlap of reproductive and obstetric challenges, PCOS should be considered a condition that spans the entire reproductive lifespan rather than a disorder confined to adolescence or early adulthood. Although many international studies have described these outcomes, prospective data from Indian tertiary centers remain scarce. Considering the high prevalence of obesity and insulin resistance in Indian women, it is possible that local patterns of complications may differ from those reported in Western cohorts [15]. This study was therefore undertaken to prospectively document both gynecological and obstetric outcomes among women with PCOS in a tertiary care hospital in North India, aiming to provide locally relevant insights into maternal and neonatal risks.

Study Design and Setting This was a prospective observational study conducted in the Department of Obstetrics and Gynecology at a tertiary care hospital in North India from January 2025 to June 2025. Ethical approval was obtained from the Institutional Ethics Committee. Written informed consent was obtained from all participants. Study Population A total of 520 women of reproductive age (20–38 years) diagnosed with PCOS were enrolled. Diagnosis was based on Rotterdam criteria (2003) requiring at least two of the following: 1.Oligo/anovulation 2. Clinical/biochemical hyperandrogenism 3. Polycystic ovarian morphology on ultrasound Exclusion criteria included women with pre-existing diabetes, chronic hypertension, thyroid dysfunction, or other endocrine disorders. Data Collection A structured proforma was used to collect: ● Baseline demographics: age, BMI, parity ● Gynecological history: infertility, menstrual irregularities, prior miscarriages ● Obstetric outcomes: GDM, PIH, preterm birth, miscarriage, mode of delivery ● Neonatal outcomes: birth weight, NICU admission Outcome Measures The primary outcomes were rates of infertility, miscarriage, preterm birth, GDM, PIH, cesarean delivery, and NICU admission. Secondary outcomes included maternal BMI and age associations with complications. Statistical Analysis Data were analyzed using SPSS v25. Descriptive statistics were expressed as means, standard deviations, and proportions. Associations were tested using chi-square and t-tests, with significance set at p < 0.05.

Baseline Characteristics A total of 520 women with a diagnosis of polycystic ovary syndrome (PCOS) were included in the study. The mean age of participants was 28.8 ± 4.2 years (range 20–38 years). A majority of women (62%) belonged to the 25–32 year age group, while 28% were <25 years and 10% were >32 years. Baseline demographic details are depicted in table 1. The mean body mass index (BMI) was 29.3 ± 3.8 kg/m², with 44% of women classified as obese (BMI ≥30 kg/m²), 38% overweight (BMI 25–29.9), and only 18% within the normal range (BMI <25). Notably, women in the obese category exhibited more severe gynecological and obstetric complications than those in lower BMI groups. Figure 1 summarises the maternal and neonatal Outcomes in Women with PCOS Table 1: Baseline Demographics of Women with PCOS Characteristic Value Mean Age (years) 28.8 ± 4.2 Age Range (years) 20–38 Mean BMI (kg/m²) 29.3 ± 3.8 Normal BMI (<25) 18% Overweight (25-29.9) 38% Obese (≥30) 44% Table 2 summarises the maternal outcomes in PCOS pregnancies Outcome Rate (%) Infertility 51.2 Miscarriage 52.3 Preterm Birth 53.5 GDM 45.6 PIH 51.2 Cesarean Section 48.3 Table 2: Maternal Outcomes in PCOS Pregnancies Gynecological Outcomes Infertility Out of 520 participants, 266 women (51.2%) reported difficulty conceiving despite regular unprotected intercourse for at least one year. Primary infertility was documented in 72% of these cases, while the remainder had secondary infertility. The prevalence of infertility was significantly higher among women with BMI ≥30 kg/m² (58%) compared with those with BMI <25 (38%, p < 0.05). This suggests a strong correlation between adiposity, insulin resistance, and anovulatory infertility in PCOS. Furthermore, women aged >32 years had a disproportionately higher prevalence of infertility (65%), likely due to the combined effect of advancing age and PCOS-related ovulatory dysfunction. Miscarriages A history of at least one miscarriage was reported by 272 women (52.3%), which is considerably higher than rates in the general population. Of these, 60% experienced first-trimester losses, while 40% reported second-trimester or later pregnancy losses. Women with infertility (particularly those requiring ovulation induction) had significantly higher miscarriage rates compared with those who conceived spontaneously (p < 0.05). Interestingly, miscarriage rates were slightly higher in the obese subgroup (55%) compared with non-obese women (47%), though this did not reach statistical significance. Obstetric Outcomes Preterm Birth A total of 278 women (53.5%) delivered preterm (<37 weeks). Among them, 62% were spontaneous preterm births and 38% were iatrogenic, mainly due to pregnancy complications such as preeclampsia or poorly controlled GDM. Preterm delivery was strongly associated with maternal complications: ● Women with GDM had a 62% preterm birth rate vs. 45% in those without GDM (p < 0.01). ● Women with PIH had a 66% preterm birth rate vs. 40% in normotensive women (p < 0.001). This highlights the cascading effect of maternal comorbidities on perinatal outcomes in PCOS pregnancies. Gestational Diabetes Mellitus (GDM) A diagnosis of GDM was made in 237 women (45.6%) during the study period, with diagnosis based on standard oral glucose tolerance test thresholds. The prevalence of GDM was significantly higher in the obese subgroup (58%) compared with overweight (46%) and normal BMI women (28%, p < 0.001). Age was also a significant factor: women >32 years had the highest GDM prevalence (63%), compared with 39% in those <25 years. Pregnancy-Induced Hypertension (PIH) PIH was documented in 266 women (51.2%), of whom 70% developed gestational hypertension and 30% developed preeclampsia. As with GDM, PIH was more common in obese women (61%) and in women >32 years (68%) compared with younger, non-obese participants. There was a strong association between PIH and preterm delivery, with hypertensive women twice as likely to deliver before 37 weeks. Mode of Delivery The cesarean section rate in the study population was 48.3% (251/520) figure 2. Indications included: ● Failed induction of labor (27%) ● Fetal distress (22%) ● Severe preeclampsia (20%) ● Previous cesarean section (18%) ● Macrosomia or malpresentation (13%) The cesarean rate was significantly higher in women with metabolic complications: ● Cesarean in GDM: 56% vs. 42% in non-GDM (p < 0.05) ● Cesarean in PIH: 61% vs. 37% in normotensive women (p < 0.001) Women with both GDM and PIH had the highest cesarean rate (68%). Neonatal Outcomes NICU Admissions A total of 271 neonates (52.1%) required NICU admission. The most common indications were prematurity-related complications (respiratory distress syndrome, sepsis, jaundice), hypoglycemia (particularly in infants of GDM mothers), and low birth weight. NICU admission was more frequent among neonates of mothers with GDM (61% vs. 46%, p < 0.01) and PIH (65% vs. 40%, p < 0.001). Table 3 summarises the neonatal outcomes. Table 3: Neonatal Outcomes in PCOS Pregnancies Birth Weight Outcome Rate (%) NICU Admission 52.1 Low Birth Weight (<2.5kg) 32.0 Normal Weight (2.5–4kg) 61.0 Macrosomia (>4kg) 7.0 ● Low birth weight (<2.5 kg) was noted in 32% of neonates. ● Macrosomia (>4 kg) occurred in 7%, predominantly among infants of GDM mothers. ● Average birth weight across the cohort was 2.7 ± 0.6 kg. Interestingly, while low birth weight was linked with maternal PIH and preterm birth, macrosomia was strongly associated with GDM. Figure 3 depicts the birth weight distribution of neonates born to PCOS mothers. Subgroup Analyses BMI-Stratified Outcomes ● Normal BMI (<25, n=94): GDM 28%, PIH 35%, preterm 39%, cesarean 37%, NICU admission 40%. ● Overweight (25–29.9, n=198): GDM 46%, PIH 48%, preterm 52%, cesarean 45%, NICU admission 49%. ● Obese (≥30, n=228): GDM 58%, PIH 61%, preterm 66%, cesarean 57%, NICU admission 63%. These findings reinforce obesity as a major determinant of poor outcomes in PCOS pregnancies and are depicted in figure 4 and table 4. Table 4: Association between BMI Categories and Obstetric/Neonatal Outcomes Outcome Normal BMI (<25) Overweight (25-29.9) Obese (≥30) p-value GDM 28% 46% 58% <0.001 PIH 35% 48% 61% <0.001 Preterm Birth 39% 52% 66% <0.001 Cesarean 37% 45% 57% 0.01 NICU Admission 40% 49% 63% <0.001 Age-Stratified Outcomes ● <25 years (n=146): Lower rates of GDM (39%) and PIH (42%), but still higher than general population norms. Preterm birth 47%, cesarean 42%. ● 25–32 years (n=322): Intermediate risk group; GDM 45%, PIH 50%, preterm 54%, cesarean 49%. ● >32 years (n=52): Highest-risk group; GDM 63%, PIH 68%, preterm 71%, cesarean 61%. This shows a clear gradient of worsening outcomes with advancing age among PCOS women. Figure 5 summarises the findings. Statistical Associations Multivariate logistic regression (table 5) showed: ● BMI ≥30 independently predicted GDM (OR 2.6, 95% CI 1.8–3.7) and PIH (OR 2.1, 95% CI 1.5–2.9). ● Age >32 years was a significant predictor of both infertility (OR 1.9, 95% CI 1.2–3.0) and miscarriage (OR 2.2, 95% CI 1.4–3.4). ● Presence of GDM increased risk of preterm birth (OR 2.0, 95% CI 1.3–3.1) and cesarean delivery (OR 1.8, 95% CI 1.2–2.7). ● PIH was the strongest predictor of NICU admission (OR 2.9, 95% CI 1.9–4.5). Table 5: Multivariate Logistic Regression Analysis of Predictors of Adverse Outcomes Predictor Associated Outcome Odds Ratio (95% CI) p-value BMI ≥30 GDM 2.6 (1.8–3.7) <0.001 Age >32 years Miscarriage 2.2 (1.4–3.4) 0.001 GDM Preterm Birth 2.0 (1.3–3.1) 0.002 PIH NICU Admission 2.9 (1.9–4.5) <0.001 Summary of Key Findings 1. High prevalence of infertility (51.2%) and miscarriage (52.3%) in women with PCOS, particularly in obese and older women. 2. Substantial maternal complications: GDM in 45.6% and PIH in 51.2%, both significantly higher than background population rates. 3. Over half experienced preterm birth (53.5%), largely associated with maternal complications. 4. Nearly half required cesarean delivery (48.3%), most often for failed induction, preeclampsia, or fetal distress. 5. Neonatal morbidity was high: NICU admissions in 52.1%, with low birth weight and prematurity being predominant causes. 6. Age and BMI were independent predictors of poor outcomes, underscoring the synergistic effect of metabolic and demographic factors.

This prospective study provides important insights into the obstetric and gynecological challenges faced by women with PCOS in a North Indian tertiary hospital setting. The findings show that infertility, miscarriage, GDM, pregnancy-induced hypertension, preterm births, cesarean sections, and neonatal complications were all significantly more common in this group compared with what is typically reported in the general obstetric population. Infertility and reproductive health More than half of the women in our study reported infertility, a figure consistent with global estimates but particularly concerning in a population where delayed presentation to fertility clinics is common [7]. Chronic anovulation, insulin resistance, and endometrial dysfunction are recognized contributors [1,4,10]. The high rates of infertility observed in older and obese subgroups highlight the need for earlier screening and referral, as timely ovulation induction or assisted reproduction may improve outcomes in this population. Pregnancy loss Miscarriage rates exceeded 50% in our cohort, which is higher than many Western reports where rates range between 20–40% [9]. Several factors could account for this difference. Apart from biological contributors such as hyperinsulinemia, hyperandrogenism, and obesity [8,10,14], health system factors in India — including inconsistent preconception counseling, late antenatal registration, and variable access to progesterone or anticoagulant support — may play a role. These findings emphasize that preventive counseling and individualized antenatal monitoring are particularly relevant in South Asian women with PCOS. Gestational diabetes and hypertension The very high rates of GDM (45.6%) and PIH (51.2%) observed here are striking when compared to the general Indian obstetric population, where prevalence is typically 10–20% for GDM and 8–12% for hypertensive disorders [11,12]. This reinforces the role of PCOS as an independent risk factor for metabolic complications during pregnancy. The strong association between obesity and these outcomes in our cohort supports the need for preconception weight optimization and early metabolic screening in all women with PCOS. In practice, universal early oral glucose tolerance testing and close blood pressure monitoring should be considered standard of care for this group. Preterm births and neonatal risks Preterm delivery was observed in over half of participants, and neonatal morbidity was correspondingly high, with more than half of newborns requiring NICU admission. These rates are much higher than national averages for preterm birth (~13%) and NICU admissions [16]. Our data suggest that maternal GDM and PIH substantially increase the likelihood of preterm delivery, and in turn, neonatal complications such as respiratory distress, hypoglycemia, and low birth weight. These findings underline the importance of perinatal preparedness, including antenatal corticosteroid use, timely referral to centers with NICU support, and multidisciplinary planning between obstetricians, endocrinologists, and neonatologists. Cesarean section The cesarean delivery rate (48.3%) in our study was nearly double the national average [13]. This reflects a combination of maternal complications, fetal compromise, and higher induction rates in PCOS pregnancies. While cesarean delivery can be life-saving, the high rates raise questions about long-term maternal health and future reproductive morbidity. Optimizing induction protocols and ensuring individualized labor management could help reduce unnecessary surgical interventions. Regional comparison Interestingly, the magnitude of complications in this North Indian cohort appears higher than that reported in Western populations [13]. South Asian women are known to develop insulin resistance and central obesity at lower BMI thresholds, which may partly explain the difference [5]. These findings point to the importance of generating region-specific data to inform clinical practice and guidelines. Strengths and limitations The prospective nature of our study and the relatively large sample size strengthen the reliability of the results. However, being a single-center study without a non-PCOS control group, the findings cannot be generalized to all populations. The short follow-up period also limited assessment of long-term maternal and neonatal outcomes. Despite these limitations, the study offers valuable real-world evidence from an Indian tertiary care setting. Clinical and public health implications The study highlights that PCOS should not be seen only as a gynecological disorder, but rather as a chronic condition with implications for fertility, pregnancy, and long-term metabolic health. Early diagnosis in adolescence, structured weight management programs, and preconception counseling can play a critical role in improving outcomes. From a public health perspective, integrating PCOS-specific screening into routine maternal care pathways could help reduce the burden of adverse obstetric outcomes. Future Directions Further multicentric studies including control groups are required to quantify relative risks more accurately. Longitudinal research following mothers and offspring could shed light on intergenerational transmission of metabolic risk. Finally, interventional trials assessing lifestyle modifications and pharmacological approaches (metformin, myo-inositol) may provide strategies to mitigate risks.

This prospective study demonstrates that women with PCOS in North India experience disproportionately high rates of infertility, miscarriage, GDM, PIH, preterm birth, cesarean delivery, and adverse neonatal outcomes. These findings highlight the dual challenge of reproductive dysfunction and metabolic risk in PCOS pregnancies. Multidisciplinary care, preconception counseling, early risk stratification, and vigilant antenatal monitoring are essential to improving outcomes. Policymakers and clinicians must recognize PCOS as a significant public health issue requiring long-term, integrated management.

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