Continuing Education Activity

The global prevalence of obesity has significantly increased in the past decades, and the World Health Organization (WHO) has described the phenomenon as a “global epidemic,” with the number of overweight and obese people nearly tripling between 1975 and 2016. Accordingly, the incidence of maternal obesity has also been increasing, and this has become one of the most important health issues in pregnancy. Globally, the prevalence of overweight and obesity varies greatly. Obesity during pregnancy contributes to increased morbidity from the prenatal period to the post-partum period and can even affect offspring's health into adulthood, related to fetal programming. Clinicians need to be aware of potential prenatal complications, including increased risk of neural tube defects, preeclampsia, gestational diabetes, spontaneous abortion, and stillbirth. Delivery complications include increased risk of Cesarean sections, longer time to dilation, increased risk of thromboembolism, and infection. Post-partum women with obesity during pregnancy can have a harder time losing the weight gained during pregnancy and have other health problems. 

Clinicians must be aware of societal guidelines, recommended interventions, advised monitoring, and appropriate weight gain for the recommended body mass index. Following these guidelines will help improve outcomes for this burgeoning issue facing women with pregnancy and obesity.

Objectives:

• Identify maternal complications associated with obesity in pregnancy.
• Identify fetal and neonatal complications associated with obesity in pregnancy.
• Explain the importance of long-term adverse health outcomes associated with fetal overnutrition.
• Review the current guidelines used by the interprofessional team in the management of obesity in pregnancy.

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Introduction

The global prevalence of obesity has risen markedly over recent decades, prompting the World Health Organization to label it a “global epidemic”; the number of people with overweight or obesity nearly tripled between 1975 and 2016. [1] The World Obesity Federation projects that by 2030 more than 1.13 billion adults will have obesity, with lifetime exposure to high BMI becoming common by ages 65–70. [2] Parallel trends are seen in pregnancy: the prevalence of maternal obesity is increasing worldwide, with marked regional variation—particularly high among women in Pacific Island nations, the Caribbean, and the Middle East—and an estimated 39 million pregnancies annually complicated by maternal obesity. Contemporary data from 2024–2025 report obesity prevalence of 40–46% among pregnant women in some populations, representing a substantial rise over prior decades. [3] [2] Rates are highest among older mothers, minority ethnic groups, and populations experiencing higher deprivation.[4] Maternal obesity is associated with gestational hypertension, gestational diabetes, preeclampsia, preterm birth, and pregnancy loss, and it increases the risk of fetal congenital anomalies and macrosomia. [5] Moreover, in-utero exposure to maternal obesity is linked to adverse cardiometabolic health in offspring that can persist into adulthood. [6] 

Function

Body mass index (BMI) can be calculated by a person's weight in kilograms divided by the square of height in meters and can help conveniently categorize one's body mass into different weight categories. BMI has been shown to be moderately correlated with direct measures of body fat and has been shown to be strongly correlated with different metabolic risk factors and disease outcomes.[7] 

In adults, BMI of 18.5 to 24.9 kg/m² is defined as normal, while BMI of 25.0 to 29.9 kg/m² is categorized as overweight, and BMI greater than 30.0 kg/m² pertains to the obese category.[8] Although the increase in body water content in pregnancy makes the correlation of the increasing BMI to morbidity less robust, BMI is still frequently utilized for screening and monitoring obesity in pregnancy.[9]

The U.S. Institute of Medicine (IOM) has issued recommendations regarding optimal gestational weight gain (GWG) in pregnancy to optimize maternal and infant outcomes. IOM suggests a total GWG of 11 to 20 lb (5 to 9 kg) for women who are obese and 15 to 25 lb (6.8 to 11.3 kg) for women who are in the overweight category.[10] 

However, the IOM recommendations were derived from observational studies that predominantly consisted of women of European origin, and their generalization to other racial and ethnic groups and other low-middle income groups may not be appropriate. Outside the U.S., the adoption of the IOM recommendation varies; for instance, the UK National Institute for Health and Care Excellence (NICE) does not endorse the IOM recommendations as the evidence is considered insufficient to guide clinical practice. Despite its limitations, IOM gestational weight gain guidelines can provide clinicians with a basis for practice in managing obesity in pregnancy.[11]

The American College of Obstetricians and Gynecologists states that obesity in women is such a common problem that the implications relative to pregnancy are often unrecognized, overlooked, or ignored because of a lack of evidence-based treatment options.[12] Therefore, management should begin before pregnancy and should continue up to the postpartum period. The management of obesity requires long-term approaches ranging from population-based public health and economic initiatives to individual nutritional, behavioral, or surgical interventions.

The International Federation of Gynecology and Obstetrics (FIGO) committee published the following guidelines for the management of prepregnancy, pregnancy, and postpartum obesity:[13]

Table

Time point A: Pre-Pregnancy

Issues of Concern

Maternal Complications

Obesity in pregnancy increases the risk for both maternal and fetal complications. Gestational diabetes (GDM), defined as new onset of glucose intolerance during pregnany in women without preexisting diabetes, is one of the most common complications associated with obesity in pregnancy. During pregnancy, there is a normal increase in insulin resistance mediated by placental secretion of diabetogenic hormones, such as growth hormone, corticotropin-releasing hormone, placental lactogen, and prolactin.[14] 

Studies have shown that obese women have a greater decrease in insulin sensitivity during pregnancy than normal-weight women and subsequently are at an increased risk of not only GDM but also associated morbidities, including preeclampsia, gestational hypertension, macrosomia, and cesarean deliveries.[6] The risk of miscarriage and congenital anomalies has also been shown to increase with hyperglycemia during organogenesis. Venous thromboembolism (VTE) is another serious risk in obese pregnant women. One study showed that up to 57% of women in the UK who died from VTE during pregnancy were in the obese category.[15] Decreased mobility, comorbid conditions such as preeclampsia, and increased frequency of operative delivery are thought to contribute to the increased risk of thrombosis in obese pregnant patients.

Furthermore, obesity in pregnancy increases the risk of complications during labor and delivery. Observational studies have shown that women with higher BMIs have increased risk of the following complications: 1) gestational diabetes, 2) preeclampsia, 3) spontaneous abortion, 4) unexplained stillbirth, 5) anesthetic complications, 6) cesarean delivery, 7) longer induction to labor, 8) infectious complications, and 9) thromboembolic events.[16][17] Recent 2024-2025 meta-analyses have provided more precise risk estimates, with studies showing that maternal obesity is associated with a 2-3 fold increased risk of preeclampsia, gestational diabetes, and cesarean delivery. For women with Class III obesity, the risk of maternal ICU admission increases up to 5-fold compared to normal weight women.[3] [2] [18]

Fetal/Neonatal Complications

Beyond materanl risks, obesity in pregnancy is associated with fetal and neonatal complications. No one unifying mechanism is responsible for the adverse outcomes associated with maternal obesity, but increased insulin resistance, inflammation, and oxidative stress associated with obesity can contribute to early placental and fetal dysfunction.[6] Studies have shown that obese women have an increased incidence of miscarriage and stillbirth compared to women of normal weight.[19] 

It has also been shown that there is a several-fold increased incidence of congenital anomalies such as spina bifida, omphalocele, and cardiac defects in obese pregnant women.[20] Whereas neural tube defects are often prevented with folic acid supplementation for conditions unrelated to obesity, neural tube defects persisted in obese women despite consuming a diet fortified with folic acid.

Macrosomia, or large for gestational age (LGA), is another neonatal complication associated with obesity in pregnancy and increases the risk for operative delivery, poor delivery outcomes, and maternal and infant traumatic injuries.[21] Macrosomia is associated with maternal complications such as protracted or arrest of labor, uterine rupture, genital tract lacerations, and/or postpartum hemorrhage. Neonates who are LGA have an increased risk of shoulder dystocia, clavicular fractures, brachial plexus injuries, and nerve palsies.

Clinical Significance

Current guidelines for the management of obesity in pregnancy are provided by the American College of Obstetricians and Gynecologists (ACOG), the International Federation of Gynecology and Obstetrics (FIGO), and the Institute of Medicine (IOM). ACOG recommends calculating body mass index (BMI) at the first antenatal visit and counseling patients using the IOM gestational weight-gain (GWG) recommendations. For women with a BMI ≥30 kg/m², the suggested total GWG is 11–20 lb (5–9 kg), with a mean of approximately 0.5 lb (0.23 kg) per week during the second and third trimesters.

Behavioral lifestyle interventions emphasizing balanced nutrition and physical activity are first-line strategies to reduce excessive GWG in overweight and obese pregnant women. Ideally, counseling should begin during the preconception period to help patients reach a healthy weight before pregnancy. Optimizing maternal weight and metabolic health can mitigate insulin resistance, inflammation, oxidative stress, and lipotoxicity, thereby reducing adverse outcomes for both mother and fetus.

A randomized controlled trial involving 124 pregnant women demonstrated that monitored physical activity exceeding 5,000 daily steps resulted in significantly greater weight control and improved obstetric and neonatal outcomes compared with unmonitored activity. [22]

Excess gestational weight gain and pre-existing maternal obesity are associated with long-term programming effects on offspring health. Children born to mothers with obesity have a higher risk for adipose tissue dysfunction, type 2 diabetes with peripheral insulin resistance and β-cell dysfunction, cardiovascular disease, and hypertension due to vascular and renal alterations. [23] In addition, these offspring have a higher risk of developing nonalcoholic fatty liver disease later in life. [24] 

Emerging Pharmacological Considerations: GLP-1 Receptor Agonists

The growing use of glucagon-like peptide-1 (GLP-1) receptor agonists for weight management and diabetes control has introduced new considerations for reproductive-age women. Agents such as semaglutide (Ozempic, Wegovy) and liraglutide have become increasingly popular, with marked uptake since 2020. [25][26]]

 Clinical Recommendations: Current guidance advises that GLP-1 receptor agonists should not be deliberately used during pregnancy. Women of reproductive age should be counseled about:

1. Preconception Use: Emerging evidence suggests that preconception GLP-1 receptor agonist use may be associated with decreased adverse obstetrical outcomes, though paradoxically, some studies report greater gestational weight gain in women with prior GLP-1 exposure compared to matched controls.[25] [27] 
2. Safety Data: Early reassurance comes from multicenter observational studies showing no increased risk of major congenital malformations with first-trimester exposure (adjusted RR 0.95, 95% CI 0.72-1.66) or major cardiac malformations (adjusted RR 0.68, 95% CI 0.42-1.12). However, larger studies are needed to confirm these findings.[28]
3. Inadvertent Pregnancy Exposure: Studies from 2024–2025 indicate that only 21% of women prescribed GLP-1 agents use effective contraception. Approximately 2.2% become pregnant within six months of starting therapy, with highest rates among younger women with diabetes and those with polycystic ovary syndrome (PCOS).[29] 
4. Fertility Considerations: Weight loss from GLP-1 receptor agonists may improve fertility in women with obesity or polycystic ovary syndrome, potentially leading to unplanned pregnancies. Women with PCOS using GLP-1 receptor agonists are twice as likely to conceive compared to those not using these medications.[29]

Bariatric Surgery and Pregnancy: Expanded Considerations

With the increasing prevalence of bariatric surgery among women of reproductive age (approximately 80% of bariatric surgery patients are women), pregnancy after metabolic bariatric surgery has become increasingly common and requires specialized periconception and prenatal care. [30] [31] 

Benefits of Bariatric Surgery for Pregnancy Outcomes:

• Significantly reduced rates of gestational diabetes mellitus and preeclampsia compared to pregnant women with similar pre-surgery BMI
• Decreased risk of delivering large-for-gestational-age infants
• Improved fertility, with pregnancy rates in adolescents post-bariatric surgery being twice that of the general adolescent population (12.8% vs 6.4%) [31]

Risks and Concerns:

• Higher incidence of small-for-gestational-age infants (2–3 × that of non-surgical pregnancies)
• Elevated risk of stillbirth, particularly with Roux-en-Y gastric bypass
• Potential for internal herniation presenting as acute abdominal pain during pregnancy
• Higher rates of nutritional deficiencies require intensive monitoring and supplementation [30] [32] 

Management Recommendations:

• Timing of conception: Delay pregnancy 12–24 months post-surgery to ensure weight stabilization and avoid exposure during rapid catabolic weight loss. [31]]

• Nutritional monitoring: Evaluate protein, iron, ferritin, folate, calcium, vitamin B12, and vitamin D at pregnancy onset, repeating each trimester or more frequently if abnormalities occur. Malabsorptive procedures such as RYGB require more intensive supplementation than restrictive procedures like adjustable gastric banding. [32] [33] 
• Contraception counseling: Because oral contraceptive absorption may be unreliable after bariatric surgery, non-oral methods (IUDs, implants, or injections) are preferred. Counseling should be provided before surgery and reinforced regularly.  [31] 
• Multidisciplinary care: Optimal management involves a high-risk obstetrician, bariatric surgeon, registered dietitian, and early anesthesiology input given increased cesarean delivery risk. [30] [32] 
• Fetal Growth Monitoring: Enhanced surveillance for SGA is recommended, with consideration of serial growth ultrasounds in the third trimester to detect intrauterine growth restriction.[33] 

Contemporary Considerations for Timing and Mode of Delivery

Recent evidence from 2024-2025 has refined recommendations for timing and mode of delivery in obese pregnant women, particularly those with Class III obesity (BMI ≥40 kg/m²):[34]

1. Timing of Delivery: Population-based studies demonstrate that stillbirth risk in obese women increases significantly from 34 weeks gestation and rises sharply beyond 42 weeks, with a 10-fold increase in Class III obesity compared to normal weight women. This has led to consideration of elective induction at 39-40 weeks of gestation for women with Class III obesity, particularly in the absence of other complications.

2. Induction of Labor: Evidence supports offering induction of labor to obese women as a planned delivery option:

• Successful vaginal delivery rates of 60% in nulliparous and 90% in multiparous women with Class III obesity.
• Induction of labor remains cost-effective until cesarean section rates exceed 70%.
• Should be offered from 41+0 weeks for low-risk obese women to reduce risks including stillbirth and neonatal intensive care admission.

3. Place of delivery: Women with BMI 30-35 kg/m² require individual assessment when planning place of birth; women with BMI >35 kg/m² should be offered referral to an obstetric unit with appropriate equipment and expertise.

Other Issues

[35] Long-Term Effects and Fetal Programming

The long-term effects of obesity in pregnancy extend beyond delivery. Compared with normal-weight women, those with obesity tend to retain more weight postpartum. Recent studies indicate that postpartum weight retention is most strongly associated with weight gain during the first trimester. [35]

Intrauterine exposure to maternal obesity can lead to adverse health outcomes in offspring, including an increased incidence of metabolic syndrome and obesity during childhood. Childhood obesity is often carried into adulthood, suggesting that fetal overnutrition may predispose to chronic disease across the lifespan. [36]

This process is attributed to fetal programming—the physiologic and metabolic adaptations the fetus makes in response to an excess nutritional environment. These adaptations can have lifelong effects, contributing to hypertension, cardiovascular disease, and type 2 diabetes in later life. [16]

Epigenetic Mechanisms of Maternal Obesity Effects on Offspring

Recent advances in the field of Developmental Origins of Health and Disease (DOHaD) highlight epigenetic mechanisms through which maternal obesity programs offspring health outcomes. These mechanisms explain how obesity and metabolic disease risk can be transmitted across generations. [37]  [38]

Key Epigenetic Modifications:

1. DNA Methylation Changes: Maternal obesity induces specific DNA methylation patterns in offspring that persist into childhood and adulthood. Studies have identified differentially methylated regions in genes involved in:

• Metabolic regulation (e.g., leptin, adiponectin systems)
• Immune function (interferon-gamma signaling pathway)
• Glucose homeostasis (CAMK2B, associated with birthweight and type 2 diabetes risk)
• More than 14% of the increased risk of early-onset obesity related to maternal pre-pregnancy BMI may be mediated through specific methylation changes [37] [39] 

2. Histone Modifications: Maternal obesity and high-fat diet exposure during pregnancy alter histone methylation and acetylation patterns in placental and fetal tissues, affecting:

• Chromatin accessibility in regions promoting glycolysis vs. oxidative phosphorylation
• Expression of hypothalamic appetite-regulating neurons (leptin receptor, POMC, neuropeptide Y)
• Central reward system molecules affecting eating behavior [38] [40] 

3. Placental Epigenetic Changes: The placenta shows significant epigenetic remodeling in response to maternal obesity:

• Over 5,600 differentially methylated or hydroxymethylated genes identified across the genome in obese vs. lean pregnancies
• Altered expression of lipid metabolism genes (ACOX1, CPT2, AMPKα, LPL)
• Changes in α-ketoglutarate levels and TET enzyme function, critical for DNA demethylation [37] [41] 

4. Immune System Programming: Maternal obesity induces epigenetic reprogramming of fetal immune cells with long-lasting consequences:

• Altered DNA methylation in cord blood monocytes affecting inflammatory gene expression
• Reprogramming of hematopoietic stem and progenitor cells toward pro-inflammatory phenotypes
• Changes persist even after weaning to normal diet, suggesting stable epigenetic modifications [42] [43] 

5. Gut Microbiome-Epigenetic Interactions: The maternal gut microbiome influences offspring epigenetic programming through:

• Transfer of maternal microbiota to fetus affecting establishment of neonatal microbiome
• Microbiome-derived metabolites influencing epigenetic enzyme activity
• Reduced microbial diversity in maternal obesity contributing to offspring metabolic and immune dysregulation [44] [45] 

Clinical Implications:

• Understanding these mechanisms may guide development of targeted interventions
• Maternal dietary modification and exercise show promise in reversing some epigenetic changes
• The critical window for intervention appears to be preconception through early pregnancy
• Antioxidants and maternal physical activity have demonstrated improvements in offspring metabolism through epigenetic mechanisms [44] [46] 
• These findings underscore the importance of optimizing maternal metabolic health before and during pregnancy, as the epigenetic changes induced by maternal obesity may have multigenerational consequences for offspring health. [37] [38]

Enhancing Healthcare Team Outcomes

Interprofessional healthcare team members, including obstetricians, maternal-fetal medicine sepcialists, advanced practice providers, nurses, pharmacists, and dietitians, must counsel patients effectively through behavioral interventions to optimize weight through effective physical activity during pregnancy to drive optimal outcomes for both mother and child.[47] Social workers must make sure patients are in safe home environments with access to adequate nutrition. 

Ethical considerations come into play when determining treatment options and respecting patient autonomy in decision-making. Responsibilities within the interprofessional team should be clearly defined, with each member contributing their specialized knowledge and skills to optimize patient care. Effective interprofessional communication fosters a collaborative environment where information is shared, questions are encouraged, and concerns are addressed promptly. This coordination minimizes errors, reduces delays, and enhances patient safety, ultimately leading to improved outcomes and patient-centered care that prioritizes the well-being of pregnant patients with obesity.

Nursing, Allied Health, and Interprofessional Team Interventions

Early screening and management of obesity in pregnancy can help improve overall outcomes. Referrals to specialists such as endocrinologists, dietitians, or weight management programs should be considered when appropriate.

Nursing, Allied Health, and Interprofessional Team Monitoring

The Institute of Medicine (IOM) guidelines for monitoring gestational weight gain (GWG) are not universally accepted but remain a useful reference, along with BMI monitoring, for managing obesity during pregnancy.

According to the International Federation of Gynecology and Obstetrics (FIGO) recommendations,[11] reproductive-age women should be encouraged to enter pregnancy with a BMI below 30 kg/m² and, ideally, within the healthy range. Even modest preconception weight loss—achieved through nonsurgical or surgical interventions—has been shown to improve maternal health and reduce pregnancy complications. Losing weight before conception also decreases the risk of childhood obesity and improves fertility. [45]

A realistic target is a 5%–10% reduction in baseline body weight over approximately six months.[48] Individualized counseling sessions that include dietary modification, optimization of nutritional status, and a combination of aerobic and resistance exercises should be considered first-line therapy for managing obesity before conception.[48] Diet and lifestyle advice should be practical, culturally sensitive, and communicated in plain language to promote adherence. [49] Techniques such as goal setting, social support, and self-monitoring can further enhance success with behavioral interventions. [13]

Women with obesity are more likely to have nutritional deficiencies such as in vitamin D, iron, and vitamin B12, when compared to women with lower BMIs. [50] This may be due to reduced overall diet quality. [51] Dietary guidance before pregnancy should focus on achieving weight loss or preventing additional weight gain through nutrient-dense foods, following local dietary customs and evidence-based nutritional guidelines that consider age, medical history, allergies, and other individual needs. Specific dietary recommendations may vary depending on national or cultural practices and available resources. [52] Comprehensive preconception nutrition guidance can be found in the FIGO recommendations on adolescent, preconception, and maternal nutrition. [[13][53]

Due to limited safety data, weight-loss medications and bariatric surgery are not recommended around the time of conception. However, they may be appropriate for women planning pregnancy in the future—particularly those with significant obesity or comorbidities. The degree of weight loss achievable with various interventions differs, and clinicians should counsel patients to set realistic expectations.[54] Even modest reductions in weight can improve fertility and maternal health outcomes; therefore, any degree of weight loss should be encouraged, even when achieving a normal BMI before pregnancy is not feasible. [55]

Finally, mental health factors such as depression should be screened for and addressed appropriately to support effective weight management before conception. [47]

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Disclosure: Nowreen Haq declares no relevant financial relationships with ineligible companies.

Disclosure: Venkata Sushma Chamarthi declares no relevant financial relationships with ineligible companies.

Disclosure: Asia Ayabe declares no relevant financial relationships with ineligible companies.