The n e w e ng l a n d j o u r na l
Review Article
From the Departments of International
Health and Population, Family, and Re-
productive Health, Johns Hopkins
Bloomberg School of Public Health, and
the Department of Gynecology and Ob-
stetrics, Johns Hopkins School of Medi-
cine — both in Baltimore (A.A.C.); the
Mother Infant Research Institute, Tufts
Medical Center, and the Department of
Obstetrics and Gynecology, Tufts Univer-
sity School of Medicine — both in Boston
(P.M.C.); and the Department of Anes-
thesiology, Perioperative and Pain Medi-
cine, Stanford University School of Medi-
cine, Palo Alto, CA (B.T.B.). Dr. Creanga
can be contacted at ­acreanga@​­jhu​.­edu
or at 615 N. Wolfe St., Rm. E8138, Balti-
more, MD 21205.
N Engl J Med 2022;387:248-59.
DOI: 10.1056/NEJMra1801040
Copyright © 2022 Massachusetts Medical Society.
CME
at NEJM.org
248
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of m e dic i n e
Dan L. Longo, M.D., Editor
Obesity in Pregnancy
Andreea A. Creanga, M.D., Patrick M. Catalano, M.D.,
and Brian T. Bateman, M.D.​​
O
besity is the most common health problem in women of repro-
ductive age.1 Not only does obesity pose clinically significant health risks
to women during pregnancy and after delivery, but it also has long-term
health implications that require recognition and treatment.1,2 Maternal obesity
can adversely affect fetal, neonatal, and infant outcomes, with lifelong conse-
quences for the offspring. Evidence-based options for nutritional, behavioral,
and surgical management of maternal obesity are available. Ideally, such man-
agement approaches should be instituted before pregnancy and should be con-
tinued after delivery and as part of long-term care, to ensure the best possible
maternal and fetal outcomes and to prevent severe complications.1 This review
provides an overview of conditions and factors associated with obesity in preg-
nancy, as well as key management considerations for obese persons who are
pregnant or have given birth. This information is relevant not only to obstetri-
cians but to all clinicians caring for women of reproductive age, since prevention
of long-term complications associated with obesity in pregnancy requires a life-
course approach.
Epidemiol o gy
The body-mass index (BMI), defined as the weight in kilograms divided by the
square of the height in meters, is used to classify persons as underweight, over-
weight, obese, or of normal weight (see Table S1 in the Supplementary Appendix,
available with the full text of this article at NEJM.org).3 A BMI of 30 or higher is
used to define obesity in nonpregnant persons, since it represents a reasonable
cutoff in balancing sensitivity and specificity for identifying those at risk for dis-
ease from excess body fat.4 However, this definition does not account for indi-
vidual differences in frame size and lean body mass and does not take into con-
sideration the fat distribution pattern, with visceral obesity posing greater
metabolic risks than subcutaneous obesity.5
The prevalence of obesity has increased substantially among women of repro-
ductive age in the United States over the past two decades.1 The National Health
and Nutrition Examination Survey documented a 33% relative increase in the
prevalence of obesity among women 20 to 39 years of age, from 29.8% in 2001–
2002 to 39.7% in 2017–2018.6 Among women with a live birth in 2020, only 2 in
5 entered pregnancy with a normal-range BMI, whereas 26.7% were overweight
and 29.5% were obese (Fig. 1).7 These data from national sources are closely
matched by women’s self-reported information for the Pregnancy Risk Assessment
Monitoring System,8 which shows women’s awareness of prepregnancy weight
status.
Obesity before pregnancy is disproportionately prevalent among women who
identify as American Indian and Alaska Native (40%), non-Hispanic Black (39%),
n engl j med 387;3 nejm.org July 21, 2022
The New England Journal of Medicine
 Obesity in Pregnancy

or Hispanic (32%), as compared with those who

Obesity class III Obesity class II Obesity class I Overweight
identify as non-Hispanic White (26%) or non-
Normal weight Underweight Unknown
Hispanic Asian (10%) (Fig. 2).7 A considerably
100
lower proportion of women born outside the 4.8 5.0 5.3 5.5 5.8
6.8 7.0 7.3 7.6
United States (21%) than U.S.-born women (31%) 90
25.5
7.9
29.5
enter pregnancy with a BMI of 30 or higher, a 80 13.9 14.3 14.8 15.2 15.8
gap driven by the higher prevalence of obesity

Percentage of Live Births

70
classes II (BMI, 35.0 to 39.9) and III (BMI, ≥40)
among U.S.-born women.7 The proportion of 60 25.3 25.6 26.0 26.3 26.7
women with a normal-range prepregnancy BMI 50
decreases with age, yet obesity-range BMI values
are distributed similarly across age groups.7 40

K e y Infl a m m at or y a nd
Me ta bol ic Ch a nge s
The chronic positive energy balance associated
with obesity leads to increased storage of triglyc-
erides and adipocyte hypertrophy, followed by
hyperplasia from adipogenesis.9 The adipose
tissue secretes diverse cytokines, proteins, and
signals with a wide-ranging influence on the
metabolic and physiologic function of other
organs.10 Obesity is therefore associated with
chronic low-grade inflammation, which is im-
portant in the development of insulin resis-
tance.9
Before and during pregnancy, women with
obesity have greater insulin resistance than
women of normal weight.11,12 The increased in-
sulin resistance in pregnant women with obesity
affects all glucose, lipid, and protein metabo-
lism.11-14 Mechanisms leading to altered insulin
resistance during pregnancy are not well charac-
terized but are thought to include factors such as
human placental lactogen,15 placental growth
hormone,16 and microRNA of placental origin17;
decreases in adiponectin13; and increases in pro-
inflammatory cytokines, especially tumor necro-
sis factor α.18 Irrespective of the cause, a rapid
reduction in insulin resistance occurs within
days after delivery, suggesting that the placenta
plays a central role in the process.15
Given such inflammatory and metabolic
changes, obesity is associated with a range of
pregnancy-related and other medical complica-
tions, including maternal death (Fig. 3).19,20 De-
spite small absolute risks of maternal death and
severe complications at the population level,19
obesity has broad implications for women’s
health before, during, and after pregnancy, as
discussed below20 (Fig. 4 and Table S2).
30
43.1 42.2 41.2 40.1 39.2
20
10
3.4 3.3 3.1 3.0 2.8
0
2016 2017 2018 2019 2020
Figure 1. Trends in the Distribution of Live Births in the United States
­According to Maternal Prepregnancy Body-Mass Index (BMI), 2016
through 2020.
Data on live births are from the Centers for Disease Control and Prevention
(CDC), National Center for Health Statistics, Division of Vital Statistics,
and are available as public-use data on the CDC WONDER online database
(http://wonder​.­cdc​.­gov/​­natality​-­expanded​-­current​.­html). The total number
of live births in the United States from 2016 through 2020 was 18,954,274.
Maternal prepregnancy BMI data were not available for 2.4% of those
births.
A n tepa r t um C ondi t ions
Subfertility and Miscarriage
Perturbations of the hypothalamic–pituitary–
ovarian axis in women with obesity may lead to
menstrual dysfunction, with a prevalence of oligo-
ovulation or anovulation that is up to 3 times as
high as the prevalence among women of normal
weight28; a lower likelihood of conception per
cycle28,29; and subfertility or even infertility.30
Obesity also can affect endometrial implanta-
tion; some of the possible effects are delayed
conception, an increased miscarriage rate, and
poorer outcomes of assisted reproductive tech-
nology treatments.30 Specifically, obesity has been
associated with a need for higher doses of go-
nadotropins, increased cycle cancellation rates,
and fewer and lower-quality oocytes retrieved31,32;
also reported are lower rates of embryo transfer,
pregnancy, and live birth and higher miscarriage
rates.31-33 Thus, women with obesity are more
likely than normal-weight women to miscarry,
regardless of whether conception is spontaneous

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 The n e w e ng l a n d j o u r na l of m e dic i n e

Obesity class III Obesity class II Obesity class I Overweight Normal weight
2%
5% 5%
8% 8% 9% 7% 8%
11% 11%
32% 33% 14%
25% 19% 37%
65% 48%
21% 19%
28% 28% 26% 31%

American Indian Non-Hispanic Asian Non-Hispanic Black Non-Hispanic White Hispanic

or Alaska Native

2%
5% 6% 5% 6% 5%
9% 8% 8% 8%
14%
42% 16% 16% 43% 16% 42%
48% 16% 45%

31%
27% 26% 27% 29%

Not U.S.-Born U.S.-Born <25 Yr of Age 25–34 Yr of Age ≥35 Yr of Age

Figure 2. Distribution of Live Births in the United States According to Maternal Prepregnancy BMI, Race or Ethnic
Group, Country of Origin, and Age, 2016 through 2020.
Data are from the CDC WONDER online database. The percentage of non-Hispanic Asian women in obesity class III
is close to zero (<1%). Data on maternal race or ethnic group were not available for 0.9% of live births, and data on
maternal country of origin (U.S.-born or not U.S.-born) were not available for 0.2% of live births.

Subfertility and miscarriage Congenital malformations

Gestational diabetes Macrosomia and large for
Hypertensive disorders Pregnancy gestational age
and Delivery Fetal
Depression Outcomes Stillbirth
Preterm birth Complications
Labor complications
Cesarean section
Obesity

Inflammation Insulin resistance

Weight retention and obesity Hemorrhage

Hyperlipidemia Infection
Type 2 diabetes Long-term Postpartum Venous thromboembolism
Ischemic heart disease Outcomes Outcomes Delayed onset and shortened
Hypertension and stroke duration of breast-feeding
Obstructive sleep apnea Depression

Figure 3. Pregnancy, Delivery, Fetal, Postpartum, and Long-Term Maternal Outcomes Associated with Obesity.

or assisted (range of adjusted odds ratios, 1.2 to The prevalence of gestational diabetes is higher
1.9),21,32 with an even higher risk of recurrent among women who are Hispanic, non-Hispanic
miscarriage.21,31-34 Black, Native American, or Asian or Pacific Islander
than among non-Hispanic White women.39 Pro-
Gestational Diabetes Mellitus posed underlying mechanisms for the increased
Meta-analyses have shown that women with risk of gestational diabetes among women with
obesity are 3 to 4 times as likely to have gesta- obesity are multifactorial and include increased
tional diabetes as normal-weight women.22,23,35-38 insulin resistance, decreased insulin response,

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 Obesity in Pregnancy

4.0
3.57
Meta-Analytic Odds Ratio 3.34 3.34

3.0
2.28 2.36 2.31
(95% CI)

1.98
2.0 1.54 1.69 1.17
1.31 1.33 1.32 1.41 1.38 1.39

1.0

0.0
ge

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ia

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Figure 4. Risk of Adverse Outcomes Associated with Obesity.
The data are from meta-analyses published between 2008 and 2021 that aimed to include a dose–response analysis
of BMI and various outcomes. The odds ratio and 95% confidence interval (CI) are shown for each of the following
outcomes: miscarriage,21 gestational diabetes,22 preeclampsia,23 antepartum depression,24 macrosomia,23 large for
gestational age,23 stillbirth,23 congenital heart defect,25 spina bifida,26 preterm birth,23 failure of labor to progress,27
cesarean delivery,23 post-term birth,23 postpartum hemorrhage,23 postpartum infection,27 and postpartum depres-
sion.24 I bars indicate 95% confidence intervals.

insulin-signaling alterations, and systemic in- Depression and Anxiety

flammation, with elevated levels of inflamma- Two meta-analyses documented significant, al-
tory markers both before and during pregnan- beit small, positive associations between obesity
cy.35 Women with gestational diabetes have an and maternal depressive symptoms and anxiety
increased risk of gestational hypertension, pre- both before and after childbirth (range of odds
eclampsia, and cesarean delivery, and diabetes is ratios, 1.3 to 1.4).24,44 The underlying mecha-
estimated to develop in up to 70% of such nisms for such associations remain uncertain
women 22 to 28 years after pregnancy.39 but are likely to include hypothalamic–pituitary–
adrenal axis and immunologic dysregulation,
Hypertensive Disorders of Pregnancy dissatisfaction with body image, experiences of
Gestational hypertension and preeclampsia stigmatization, and binge eating.24,44 Stigma as-
are more prevalent among women with obesity sociated with obesity is highly prevalent, and
than among women of normal weight, with women who repeatedly experience weight stig-
the estimated risk of preeclampsia doubling ma report more depressive symptoms, maladap-
for every increase of 5 to 7 in the BMI.40 Meta- tive eating behaviors, and stress.45 A reverse
analyses23,37,41,42 have documented a dose– causal pathway may also be at play, since women
response relationship between obesity class with poor mental health struggle with weight
and preeclampsia, with the risk 3 to 4 times management.46
as high for obesity class II or III as for class I
(BMI, 30.0 to 34.9).37 However, preeclampsia Fe ta l C ondi t ions
develops in only about 10% of women with
obesity.43 The pathogenesis of preeclampsia is Congenital Anomalies
largely unknown, but inf lammation and in- Maternal obesity has been found to be associat-
creased insulin resistance are believed to play ed with an increased risk of a range of struc-
a role.43 The metabolic and vascular phenotype tural anomalies, especially congenital heart de-
of obesity in pregnancy may partly explain the fects and neural-tube defects, with evidence of a
increased risk of cardiovascular diseases later dose–response relationship with BMI.25,26,47-51
in life for women with hypertension during The level of uncertainty regarding a causal rela-
pregnancy.10 tionship between prepregnancy obesity and these

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 The n e w e ng l a n d j o u r na l of m e dic i n e

anomalies is considered to be moderate for morbidity during hospitalization for delivery

neural-tube defects and strong for congenital
heart defects.52 The antepartum identification of
congenital anomalies may be limited in women
with obesity, since the ultrasound signal can be
attenuated by predominantly centrally stored fat.53
Macrosomia and Large for Gestational Age
Several meta-analyses have documented positive,
dose–response associations between maternal
BMI and both macrosomia (birth weight, >4000 g)
and large for gestational age (birth weight >90th
percentile for gestational age and sex); the ex-
tent to which these conditions are mediated by
diabetes mellitus is unknown.23,27,37,54,55 Most re-
cently, Vats et al. reported odds ratios of 2.28
(95% confidence interval [CI], 2.15 to 2.41) and
2.36 (95% CI, 2.17 to 2.56) for the association of
maternal obesity with macrosomia and large for
gestational age, respectively.23 Prepregnancy obe-
sity also reduces the risk of low birth weight and
small for gestational age (birth weight <10th
percentile for gestational age and sex), but the
effect appears to be small.46
Fetal Death and Stillbirth
The risk of stillbirth is 1.3 to 2.1 times as high
among women with obesity as among normal-
weight women, on the basis of several meta-
analyses.23,37,56-58 The risk per 5-unit increase in
the BMI is significant for antepartum stillbirth
(relative risk, 1.28; 95% CI, 1.15 to 1.43) but not
for intrapartum stillbirth (relative risk, 0.90;
95% CI, 0.76 to 1.06); the latter finding is most
likely the result of medical care received during
childbirth.58 Obesity-related coexisting condi-
tions (e.g., hypertension) and the possibly lim-
ited ability of women with a high BMI to notice
and seek care for decreases in fetal movement46
are potential explanations for the association
between obesity and fetal death or stillbirth.
Congenital anomalies are estimated to contrib-
ute to or cause about 5% of stillbirths. Thus,
other mechanisms may be involved in the re-
ported associations with stillbirth at increasing
BMI levels.59
among women with obesity as compared with
women of normal weight.19,20 Women with a BMI
of 50 or higher have the highest risk (adjusted
odds ratio, 1.99; 95% CI, 1.57 to 2.54).20
Preterm Birth
The association between maternal obesity and
preterm birth is controversial.23,27,37,60,61 The over-
all pooled odds ratio from the most recent meta-
analysis was significant at 1.17 (95% CI, 1.13 to
1.21).23 Significant positive associations between
obesity and preterm birth are of higher mag-
nitude at earlier gestational ages, but a dose–
response effect with BMI has not been estab-
lished.23,60 McDonald et al.61 documented
significant associations between BMI and medi-
cally indicated preterm births (<37 weeks’ gesta-
tion) for obesity class I (relative risk, 1.56; 95%
CI, 1.42 to 1.71) and obesity class II or III (rela-
tive risk, 1.71; 95% CI, 1.50 to 1.94).
Labor and Delivery Complications
Heslehurst et al.27 found higher rates of labor
induction, oxytocin augmentation, failure of la-
bor to progress, and instrumental delivery among
women with obesity as compared with normal-
weight women. Shoulder dystocia is also more
prevalent among women with obesity than
among normal-weight women,27,37,62 and the risk
is significantly increased, by a factor of 2 to 2.5,
among women with a BMI of 35 or higher.63 A
proposed mechanism for these complications is
an increase in soft tissues inside the pelvis —
narrowing the birth canal and making birth
more difficult, especially for infants with macro-
somia — coupled with a weakened response to
oxytocin.46
Also documented is a higher risk of post-term
birth with increasing BMI,23,27,62 with an odds
ratio of 1.75 (95% CI, 1.50 to 2.04) for women
with a BMI of 50 or higher.62 The altered ratio of
estrogen to progesterone in maternal plasma and
the release of cortisol and corticotropin-releasing
hormone are thought to play a role in this as-
sociation.46

Cesarean Delivery
L a bor , Del i v er y, a nd
P os tpa r t um C ondi t ions Obesity alone is not an indication for cesarean
delivery. Nevertheless, the association between
Severe Maternal Morbidity obesity and cesarean delivery has been docu-
Studies have shown significant but small in- mented in various practice settings.23,27,37,64,65 The
creases in the overall risk of severe maternal risk of cesarean delivery for women with obesity

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 Obesity in Pregnancy

is double the risk for normal-weight women, 4 times as high among parturient women with
with a dose–response relationship.37,64,65 Three a BMI of 40 or more as among those of normal
meta-analyses23,27,65 that compared risks for elec- weight.70 The study also showed that postpartum
tive versus emergency cesarean delivery among thromboembolism was less strongly associated
women with obesity showed stronger associa- with the BMI at delivery than with the prepreg-
tions with emergency cesarean delivery, but the nancy BMI, yet large weight gains (>22 kg) dur-
95% confidence intervals overlapped. Medical ing pregnancy and cesarean delivery contributed
and nonmedical factors probably contribute to to an increase in the risk of venous thromboem-
the higher rate of cesarean delivery among bolism.
women with obesity, including a decreased cer-
vical dilatation rate, the presence of coexisting Breast-Feeding Factors
conditions, concern about shoulder dystocia, Women with obesity are less likely than normal-
and excess weight gain during pregnancy.56,66 weight women to initiate breast-feeding,71-73 with
Women with obesity are also at risk for compli- the most recent meta-analysis documenting a
cations associated with cesarean delivery, such as pooled relative risk of 1.49 (95% CI, 1.33 to 1.67)
anesthesia-related complications, wound com- for women with obesity.73 For those who breast-
plications, excessive blood loss, venous throm- feed, the duration of breast-feeding is likely to
boembolism, postpartum endometritis, and fail- be shorter for women with obesity (relative risk,
ure of vaginal birth after cesarean delivery.66 1.34; 95% CI, 1.16 to 1.56), who also are less
likely to exclusively breast-feed for any period
Postpartum Hemorrhage (relative risk, 1.26; 95% CI, 1.17 to 1.36).73 Medi-
Two meta-analyses23,27 showed that women with cal, physiological, psychological, and sociocul-
obesity had higher odds of postpartum hemor- tural factors may contribute to the poorer breast-
rhage than normal-weight women; the highest feeding outcomes for women with obesity than
documented risk among women with a BMI ex- for normal-weight women. Key factors include
ceeding 35 was a pooled odds ratio of 1.43 (95% an elevated progesterone level (which prevents
CI, 1.33 to 1.54).27 A third meta-analysis did not the progesterone decline that leads to lactogen-
confirm this association.37 The increased risk esis), latching difficulties associated with large
may be due to the larger volume of distribution breasts,46 cesarean delivery, and depression.24
of uterotonic agents and greater difficulty iden-
tifying the fundus and performing bimanual M a nagemen t C onsider at ions
massage in women with obesity than in normal-
weight women. 67 Preconception Care
Women should be informed by their health care
Infection providers about the risks of obesity, including
Parturient women who are obese and are under- subfertility, and the benefits of weight loss be-
going cesarean delivery or other surgery are at fore pregnancy (e.g., reduced risks of miscar-
significantly higher risk for surgical-site infec- riage, preeclampsia, and gestational diabetes)
tions than normal-weight women, with studies and in the long term (e.g., reduced risks of hy-
documenting an increase in the risk by a factor pertension, sleep apnea, cardiac disease, and
of 2.68,69 A meta-analysis that included six studies diabetes) (Fig. 5).1,74 Recommendations should
examining any type of infection (i.e., wound, be made for lifestyle and weight-loss interven-
urinary tract, perineum, chest, or breast infec- tions. Women with chronic conditions may need
tions) in parturient women showed a signifi- a referral for specialist care and treatment.
cantly higher risk of infection for women with Women who are planning to become pregnant
obesity than for normal-weight women (pooled should take folic acid supplements daily, starting
odds ratio, 3.34; 95% CI, 2.74 to 4.06).27 before conception.74

Venous Thromboembolism Antepartum Care

Obesity is a strong risk factor for venous throm- Measured at the first visit and monitored at all
boembolism among women with obesity as com- antepartum visits, the patient’s BMI serves as
pared with normal-weight women.67 One study the basis for tailoring counseling about diet and
showed that the risk of thromboembolism is exercise and discussing the actual and appropri-

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 The n e w e ng l a n d j o u r na l of m e dic i n e

1–2 Months During Labor

Before Conception During Pregnancy After Delivery
before Delivery and Delivery

Discuss subfertility and
other obesity-associated
risks
Recommend lifestyle and
weight-loss interventions
Assess need for treatment
of or treat preexisting
conditions
Refer to specialist if needed
Provide folic acid supple-
mentation
Measure height once Ask about delivery and Induce labor by obstetrical Maintain high suspicion for
and weight at every visit breast-feeding prefer- or medical indication complications
ences
Discuss actual and appro- Place epidural catheter early Offer breast-feeding support
priate weight gain Discuss needed accommo- early
dations for adequate Monitor fetus and actively
Counsel on nutritional labor and delivery manage labor Counsel on risks associated
and exercise needs management, given with obesity for woman
obesity status Provide antibiotics and and newborn
Screen for hypertension, thromboprophylaxis
proteinuria, type 2 Schedule anesthesia as needed Counsel on family planning
diabetes, gestational consultation options
diabetes, depression, Actively manage the third
obstructive sleep apnea, Consider antenatal anti- stage of labor Recommend lifestyle and
and substance use biotics and thrombo- weight-loss interventions
prophylaxis
Recommend ultrasound Refer to specialist if needed
for dating, anatomical Coordinate other specialist
survey, and fetal growth consultations if needed

Figure 5. Management Considerations for Women with Obesity before, during, and after Pregnancy.

ate ranges of weight gain during pregnancy ac-
cording to BMI class, in line with current guide-
lines (Table S1).1 Most women need additional
calories during the second and third trimesters
to support the metabolic demands of pregnancy,
with wide variation among individual women.75
In normal-weight women, fat accumulates main-
ly in the subcutaneous compartment of the
trunk and thighs; in women with obesity, when
the storage capacity of the subcutaneous fat de-
pot is reached, fat accumulates in the visceral
compartment.76,77 It is visceral adiposity that cor-
relates more strongly with adverse metabolic
outcomes.9 Data from the Pregnancy Risk As-
sessment Monitoring System show that only
32% of pregnant women in the United States
have gestational weight gain within the cur-
rently recommended range; for women with
overweight or obesity, the odds of excessive ges-
tational weight gain are increased by a factor of
2 to 3.78 Excessive weight gain early in preg-
nancy strongly predicts total excessive gesta-
tional weight gain, suggesting that women with
early excessive weight gain might need to be
prioritized for interventions.79 Regular exercise
is recommended, with clinical guidelines sug-
gesting 150 minutes per week74 or 20 to 30
minutes per day80 of moderate-intensity exercise.
Screening for high blood pressure, protein-
uria, depression, substance use, and obstructive
sleep apnea is recommended early in pregnancy.1
Professional organizations recommend screen-
ing for pregestational type 2 diabetes at the
initial prenatal visit, with a glucose challenge
test at 24 to 28 weeks’ gestation for gestational
diabetes if the initial testing is normal.39 Initial
treatment of mild gestational diabetes is a sim-
ple diet with controlled intake of sugar, carbohy-
drates, and saturated fats and low-impact exer-
cise.39 On the basis of the medical history, some
women, especially those with a BMI of 35 or
higher, may be advised to take at least 75 mg of
aspirin daily from 12 weeks’ gestation until the
birth of the baby in order to reduce the risk of
preeclampsia.74 Ultrasound assessments are sug-
gested at 14 to 16 weeks’ gestation for early
anatomy, at 20 to 22 weeks for routine morpho-
logic assessment, at 28 to 32 weeks to aid in the
detection of late-onset fetal growth restriction,
and anytime in the third trimester for excessive
fetal growth.74 Finally, the American College of
Obstetricians and Gynecologists (ACOG) recom-
mends weekly antenatal surveillance for fetal
well-being, starting by 34 weeks and 0 days of
gestation for women with a prepregnancy BMI
of 40 or higher and by 37 weeks and 0 days for
women with a prepregnancy BMI of 35 to 39.1
Care before Delivery
The type of delivery, breast-feeding preferences,
and special accommodations for labor and delivery
management should be discussed 1 to 2 months

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 Obesity in Pregnancy
before delivery. Referral to an anesthesiologist
is recommended in most clinical guidelines, as is
referral for other specialist consultations that
the patient may need before or after delivery
(e.g., cardiology, mental health, or substance use
consultation).74
Labor and Delivery Care
Depending on the patient’s weight, additional
staff and equipment may be needed for labor
and delivery care. Obesity alone is not an indica-
tion for labor induction, and a vaginal birth
should be encouraged.79 Similarly, a history of
bariatric surgery should not be considered an in-
dication for cesarean delivery.1 Conversely, allow-
ing a long first stage of labor before a cesarean
is performed for labor arrest should be consid-
ered.1,74,81
For women with obesity, the usual doses of
prophylactic cephalosporins administered before
cesarean delivery may result in inadequate tissue
concentrations.82 Consequently, some experts
recommend increasing the preoperative dose of
cefazolin, although data regarding the clinical
benefits are mixed.83-86 Some trials also exam-
ined broadening or extending prophylactic anti-
biotic coverage for women undergoing cesarean
delivery. One study, in which a large fraction of
participants had obesity, showed that adding
azithromycin to standard antibiotic prophylaxis
for women undergoing cesarean delivery during
labor or after membrane rupture reduced the
risk of postoperative infection by approximately
half.87 Another trial, involving women with a
prepregnancy BMI of 30 or higher who were
undergoing cesarean delivery, showed a simi-
larly large reduction in surgical-site infections
associated with a prophylactic 48-hour course of
oral cephalexin and metronidazole postopera-
tively.88
Obesity presents challenges to the manage-
ment of anesthesia and heightens the risk of
anesthesia-related complications.89 Particularly
worrisome are risks associated with general an-
esthesia. A national case–control study in the
United Kingdom identified obesity as an inde-
pendent risk factor for failed tracheal intubation
(odds ratio, 1.06 per unit increase in the BMI).90
A study of obstetrical anesthesia–related deaths
further suggested that obesity increases the risk
of fatal airway obstruction and hypoventilation
during emergence and recovery from general
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anesthesia.91 Therefore, neuraxial anesthetic tech-
niques should be used whenever possible in pa-
tients with obesity.
If general anesthesia is needed, preparation
for a potentially difficult intubation should be
made, including ensuring that additional airway
equipment (e.g., video laryngoscope, gum-elastic
bougie, and laryngeal mask airways) is immedi-
ately available. Placement of an epidural catheter
early in labor is encouraged, since it can be used
to provide anesthesia if an emergency cesarean
delivery is required.92 Given the high prevalence
of obstructive sleep apnea among persons with
obesity, patients with a high BMI may be at in-
creased risk for respiratory depression from ei-
ther neuraxial or systemic opioids after cesarean
delivery. In the absence of contraindications,
nonsteroidal antiinflammatory medications and
acetaminophen should be administered in a
scheduled fashion to reduce the opioid require-
ment. When opioids are administered in patients
with obesity, monitoring with continuous cap-
nography or pulse oximetry to detect respiratory
depression should be considered.
Clinical guidelines recommend mechanical
thromboprophylaxis with the use of pneumatic
compression devices before cesarean delivery, if
possible, as well as after cesarean delivery.
Weight-based dosing of pharmacologic options
for thromboprophylaxis should be considered,
since this approach may be more effective than
BMI-stratified dosage after cesarean delivery in
women with class III obesity.1,74
Postpartum Care
In addition to the need to maintain a high level
of suspicion for delivery complications, early
breast-feeding support may be needed for wom-
en with obesity, especially after cesarean deliv-
ery. Counseling about the risks associated with
obesity for the woman and infant could be of-
fered in tandem with recommendations for be-
havioral interventions geared toward postpar-
tum weight reduction.
M a nagemen t of Obe si t y a nd
Ge s tat iona l W eigh t G a in
Environmental factors (e.g., high food consump-
tion, especially high-calorie, palatable foods;
medications with weight gain as a side effect;
and longer lifespan as a result of medical ad-
nejm.org July 21, 2022 255
 The n e w e ng l a n d j o u r na l
vances) favor a positive weight balance and
weight gain over time.93 Genetic factors also play
a role, since not all persons exposed to these
environmental factors become obese, but the
BMI heritability rate ranges from 40 to 70% in
various studies, and there are rare monogenic
forms of obesity.93 Genes and environment inter-
act to regulate the energy balance and weight
status, making obesity a chronic disease requir-
ing long-term management. The risks for obesi-
ty-associated conditions appear to be attenuated
among women without other chronic diseases,
after adjustment for age, parity, race or ethnic
group, and status regarding substance use in
pregnancy, underscoring the importance of early
obesity management.94 Antenatal lifestyle modi-
fications (i.e., healthy eating and exercise) are
important for pregnant women with obesity, can
minimize weight gain during pregnancy and
reduce the prevalence of gestational diabetes,95
and appear to be most successful if recom-
mended by prenatal health care providers.96 In
one study, women who underwent motivational
interviewing monthly for 7 to 8 months had
greater weight loss (by 2 kg) than a control
group of participants receiving emotional sup-
port.97 Loss of 5 to 10% of body weight has been
shown to improve metabolic conditioning before
pregnancy,98 restore menstrual cyclicity and ovu-
lation,30 increase the likelihood of concep-
tion,28,30,32 and reduce the risk of preeclamp-
sia.42,43 Unfortunately, lifestyle interventions
often fail when persons revert to previous eating
and exercising habits after intensive manage-
ment, suggesting that management of obesity
requires a life-course approach.
Bariatric surgery is increasingly being used.99
On the basis of international guidelines,100 pa-
tients with obesity class III and those with class
II and associated coexisting conditions may be
eligible for bariatric surgery. Bariatric surgery
has been shown to improve fertility through
ovulation restoration. In a large meta-analysis,
bariatric surgery before pregnancy was associ-
ated with reduced risks of gestational diabetes,
large for gestational age, hypertensive disorders,
postpartum hemorrhage, and cesarean delivery,
as compared with BMI-matched controls who
did not undergo bariatric surgery.99,101 Converse-
ly, bariatric surgery can be accompanied by
surgical complications, micronutrient deficien-
256 n engl j med 387;3
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of m e dic i n e
cies, and endocrine and metabolic disorders, all
of which need to be assessed.101 Adverse perina-
tal outcomes such as small for gestational age,
preterm birth, congenital abnormalities, and
perinatal mortality have also been cited, with an
increased risk among women who become preg-
nant soon after surgery.102 Thus, ACOG recom-
mends that women wishing to conceive after
bariatric surgery delay pregnancy for at least 12
to 18 months after surgery or until a stable post-
procedure weight is achieved.103
Stigma and bias, which can affect the quality
of care and the health of women with obesity
during and after pregnancy, are disproportion-
ately experienced by women with a BMI of 40 or
higher.104 A recent study identified the following
key actions to mitigate weight bias in this sub-
population: improving provider awareness of
such bias, using patient-preferred weight termi-
nology (i.e., “weight” and “BMI” rather than
“large size” and “obese”), and offering group
antepartum care focused on nutrition, physical
activity, and weight management.104
C onclusions
Obesity is the most common health problem in
women of reproductive age1 and requires long-
term management.93 Although the absolute risk
of severe adverse maternal, fetal, and newborn
outcomes is low among women with obesity,20,105
instituting healthy eating and exercising behav-
iors before pregnancy, ideally, or as early in
pregnancy as is feasible can minimize excessive
gestational weight gain and help mitigate preg-
nancy-related and long-term complications for
women and their offspring. Research is greatly
needed to better understand the associations
described in this article and their pathophysio-
logical contributors. Designing and testing the
efficacy of packages of lifestyle, behavioral, and
clinical interventions to reverse the alarming
rise in overweight and obesity in women of re-
productive age will, in turn, inform the develop-
ment of new policies and programs for pregnant
and postpartum women with obesity. Ultimately,
the shared goals of pregnant and postpartum
women and their providers are healthy pregnan-
cies, mothers, and babies.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
nejm.org July 21, 2022

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