Management of prepregnancy, pregnancy, and postpartum obesity from the FIGO Pregnancy and Non‐Communicable Diseases Committee: A FIGO (International Federation of Gynecology and Obstetrics) guideline

Abstract

Obstetricians and gynecologists are well positioned to influence population health through maternity and women’s health services. Obesity is common in women of reproductive age and the prevalence is rising in both low-/middle-income and high-income countries1. Obesity affects requirements for assessment, monitoring, and intervention and can impact maternal and child outcomes. Obstetricians and gynecologists require guidance on the care of women of reproductive age with obesity at all time points related to pregnancy, including how to address modifiable risk factors such as diet and physical activity. Many guidelines have been developed to date, although they vary in scope, methodology, and individual recommendations. FIGO’s Committee Guideline for the Management of Prepregnancy, Pregnancy, and Postpartum Obesity (Table 1) reviews good clinical practice recommendations (Table 2–4) from previously published international documents. It serves as a practical resource to support obstetricians and gynecologists in the management of women with obesity. We emphasize the role of clinicians in preventing and managing obesity for women before, during, and after pregnancy, harnessing the increased contact with healthcare professionals during this period. FIGO expects that the recommendations in this guideline will inform the development of evidence-based, country-specific guidance on the management of obesity in member organizations, that are in line with local needs, practices, policies, and available resources. Conditional Conditional Conditional Conditional Strong Obesity has become the most common medical condition in women of reproductive age and the rise in prevalence of obesity is seen in both high-income countries and low-/middle-income countries (LMICs)1. It is predicted that by 2025 more than 21% of women in the world will have obesity2. In the USA, 2011–2012 NHANES (National Health and Nutrition Examination Survey) data indicate that the prevalence of obesity in women aged 20–39 years is at least 31.8% and is even higher in women of low incomes at 61%3. The prevalence of maternal obesity varies in different African nations, ranging from 17.9% in the first trimester and up to 6.5%–50.7% in the third trimester4. Routine surveillance of weight gain during pregnancy is not conducted in many countries. However, body mass index (BMI) among women in the reproductive age group is used often as an indicator of maternal obesity and its likely effect on pregnancy outcomes and subsequent health of the woman and her child1. Obesity increases the risk of noncommunicable diseases (NCDs), such as type 2 diabetes and cardiovascular disease, which contribute to over 70% of global deaths annually5, 6. This is especially important in LMICs where 86% of premature NCD deaths occur7. Increasing evidence from the developmental origins of health and disease paradigm suggests that obesity during pregnancy not only increases the mother’s risk of later NCDs but can also transfer the risk to the offspring through epigenetic mechanisms, alterations in gut microbiome, and sociocultural factors8. In addition, excessive gestational weight gain during pregnancy can result in further elevated maternal BMI in subsequent pregnancies if weight loss is not achieved in the postpartum period, particularly in the first 6–12 months9, 10. Comorbidities such as gestational diabetes mellitus (GDM) are more common in pregnant women with obesity, and this not only increases the risk of subsequent type 2 diabetes mellitus for the mother but also leads to increased fetal growth, large-for-gestational-age babies, and metabolic compromise in the offspring11-14. These outcomes in offspring are further associated with long-term consequences such as childhood obesity and type 2 diabetes mellitus in later life15. Other long-term consequences include poor cognitive performance in the child and neurodevelopmental disorders including cerebral palsy8. Pregnant women with obesity are also more likely to deliver by cesarean and have difficulties initiating breastfeeding and a reduction in duration of breastfeeding1, 16. Obesity in pregnant mothers is also associated with immediate adverse outcomes such as stillbirth with risk increasing with higher maternal BMI17. Finally, maternal obesity places women at a higher risk of infertility18. Women with obesity are more likely to have issues with ovulation or endometrial function, and weight loss in women with obesity is associated with improved fertility19, 20. The causes of maternal obesity are multifaceted, including societal, environmental, and other factors, calling for a multisystem, life course approach to obesity prevention and management. However, obstetricians and gynecologists are uniquely positioned to influence obesity risk and prevalence through lifestyle and other interventions with women of reproductive age, before, during, and after pregnancy. The preconception and postpartum periods are opportunities for intensive nutrition and weight optimization, while during pregnancy, the focus should be on appropriate gestational weight gain while meeting nutritional requirements. Postpartum weight retention can significantly alter the weight gain trajectory of a woman during childbearing years, especially in the case of multiple pregnancies. The preconception and postpartum periods are thus key time points for weight management strategies to delay or prevent the development or progression of obesity in women, promote the health of women in pregnancy, and reduce the risks passed to future generations9. Women with obesity during pregnancy require specialist care and recommendations for this are outlined in this article. Maternity costs are higher for women with obesity due to the increased and specialized requirements associated with care and increased use of healthcare services among women with obesity21. Such issues highlight the additional importance of nutrition and weight management in the preconception and postpartum periods and to increase awareness about optimal gestational weight gain among clinicians and the general population. While healthcare models and care pathways for women before, during, and after pregnancy vary internationally, obstetricians/gynecologists and midwives are well positioned to influence population health through maternity and women’s health services. However, several barriers exist in delivering these preventive services during routine clinical practice. Often, time constraints during appointments can hamper effective discussions related to nutrition and weight management during antenatal visits22, 23. A recent review of midwives’ and obstetricians/gynecologists’ knowledge of gestational weight gain guidelines showed that, overall, healthcare professionals demonstrated inadequate knowledge of these guidelines24. Self-reported knowledge was higher than directly assessed knowledge and a pooled analysis was difficult owing to differences in guidelines between countries. In addition, cultural influences may determine the healthcare professional’s subjective perception of body image and weight and, in the absence of anthropometric measurement and classification, this could result in underestimation and assessment of weight-related risks. Resources such as the FIGO Nutrition Checklist and guidance may assist obstetricians and gynecologists by increasing professional knowledge and time management when caring for women21, 22, 25-27. Considering the increasing global rates of obesity during pregnancy and their long-term effects for the health of the mother and the next generation, it is essential to address the issue of gestational weight gain. The authors reviewed existing clinical guidelines for the management of women with obesity before, during, and after pregnancy and identify key recommendations for global clinical practice. The Pregnancy Obesity and Nutrition Initiative (PONI) developed by FIGO’s Pregnancy and Non-Communicable Diseases (PNCD) Committee emphasizes that management of obesity in pregnancy should be considered in the context of a life course approach, linking with preconception and postpartum and interconception services to prevent excess weight gain before and during pregnancy5. PONI also aims to support healthcare professionals such as obstetricians/gynecologists, midwives, nurses, dietitians, and endocrinologists to develop collaborative action to prevent and reduce the burden of maternal obesity. This guidance also outlines potential actions to address the barrier of ineffective communication of risks related to maternal obesity. To date, over 30 clinical practice guidelines have been published internationally, which focus specifically on or incorporate some guidance on the management of women with obesity during pregnancy28. These guidelines vary in scope, evidence quality, and international relevance. Therefore, this guidance for the management of prepregnancy, pregnancy, and postpartum obesity consolidates recommendations from multiple practice guidelines and suggests a pragmatic approach for the management of obesity in women before, during, and after pregnancy. This guidance is directed at healthcare providers working with women with obesity, before, during, and after pregnancy. Obesity management may require and benefit from the involvement of a variety of professionals such as general practitioners/family physicians, midwives, nurses, community health workers, dietitians, nutritionists, physiotherapists, and others29. A multidisciplinary approach to obesity management before, during, and after pregnancy is therefore recommended. The guidance outlined here is relevant to individual practitioners providing primary care, gynecological care, and support to women during pregnancy and outside of pregnancy, and their respective professional organizations. This guidance is also relevant to healthcare delivery organizations and providers as it may guide and give insight into resource requirements for this group. This includes governments, legislators, healthcare or insurance organizations, and development agencies. The article focuses on three key time points, related to pregnancy: prepregnancy (time point A), pregnancy (time point B), and the postpartum period (time point C). For the purpose of this review, obesity is defined in terms of BMI (calculated as weight in kilograms divided by the square of height in meters). According to the World Health Organization (WHO), a BMI score greater than 30 is considered to indicate obesity30. Obesity is further divided into three classes of increasing severity: obesity class I 30–34.9; class II 35–39.9; and class III greater than 40. The potential influence of ethnicity on BMI, body fat percentage, and associated risk factors for chronic disease should be considered and the general cut-offs outlined above may not be the most suitable for all populations, including some Asian populations30. The WHO recommends that each country make a decision on risk and desired BMI cut-offs based on the characteristics of their specific population and have identified a number of points along the BMI continuum that may indicate elevated risk in Asian populations. In some cases, a BMI of 23 or 27.5 may be a relevant marker of risk, in comparison to BMI of 25 and 3030, 31. FIGO member states using this resource should consider the specific BMI cut-offs that are appropriate for their population to identify women with obesity. The recommendations in this guideline will likely be relevant to the management of women with obesity, regardless of which BMI cut-off is used to define this risk. While this article focuses on the management of women with obesity, several of the risks associated with obesity likely start to increase when BMI enters the overweight category (usually defined as BMI 25–29)32, 33. Therefore, the advice may also be useful for women with a BMI in the overweight category who are at increased risk of adverse health outcomes and who may benefit from the diet, physical activity, and other interventions outlined throughout33. Published clinical practice guidelines that focus specifically on obesity in pregnancy and include evidence grading were considered for this review. Sources include the recent systematic review on published clinical practice guidelines on obesity in pregnancy28, supplemented with an independent review of grey literature, including the Geneva Foundation for Medical Education and Research34. To be included in the current review, a guideline needed to originate from a FIGO member organization, focus primarily on the management of pregnancy obesity rather than associated comorbidities such as gestational diabetes mellitus, and include some form of evidence grading to qualify recommendations. The recommendations from included guidelines were extracted, along with their evidence grading. Further details of the methods involved in this review are included in supporting information S1. There was variance in the evidence grading systems used by the clinical practice guidelines, and evidence gradings were translated to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework for consistency, based on the information in each of the clinical practice guidelines (supporting information S2)35. The interpretation of this can be seen in Tables 5 and 6. The sources of recommendations are referenced throughout this article and should be consulted for more details on the individual studies involved in the generation of the level of evidence qualifier. The clinical practice guidelines were reviewed in order of publication. Where conflicting guidance or evidence grading was provided, the guidance from the most recently published clinical practice guideline is outlined. This approach was taken as it best reflects the most up-to-date evidence. Each recommendation or set of related recommendations is followed by a summary of the rationale and evidence and remarks or caveats for operationalizing it in diverse settings, where relevant. For full details of the list of recommendations and corresponding evidence in each of the guidance documents, the specific reference document should be reviewed. The final advice in this document was agreed upon through independent review by members of the FIGO PNCD Committee and consolidation within the committee. Recommendation A.1. All women should have their weight and height measured and their body mass index calculated at each contact. A.1.1. Primary care services should support women of childbearing age with weight management before pregnancy and BMI should be measured. Advice on weight and lifestyle should be given during periodic health examinations, preconception counselling, contraceptive consultations, or other gynecologic care prior to pregnancy. Conditional The preconception and interpregnancy periods are good opportunities for safe weight management interventions. As many women of childbearing age may not attend preconception health services, other health presentations such as regular health examinations, routine gynecological appointments, and other primary care services should be utilized to check and monitor weight36. Weight and height should be measured and BMI calculated for all women of childbearing age to encourage them, if needed, to optimize their weight before pregnancy37, 38In addition, women with obesity may experience higher rates of contraceptive failure and thus may not present to healthcare services for pregnancy planning38, 39. Consideration should be given to weight monitoring in routine health checks and clinical presentations so that the individual weight trajectory of a woman can be considered. Recommendation A.2. All women with a BMI of ≥30 should be advised of the effect of obesity on fertility, the immediate risks of obesity during pregnancy and childbirth, and the subsequent long-term health effect of obesity including the higher risk of NCDs for them and their children. A.2.1. Women of childbearing age with obesity should receive information and advice about the effect of obesity on fertility and the risks of obesity during pregnancy and childbirth. Conditional Women with obesity may be unaware of the extent of adverse health outcomes of pregnancy that are related to obesity and may hold misconceptions about the relationship between diet, weight, and health in pregnancy40-42. Advice should be given to women with obesity of the effect on their fertility and the risks of obesity during pregnancy and childbirth, which include neural tube defects, macrosomia, preterm delivery, stillbirth, shoulder dystocia, cesarean delivery, GDM, metabolic syndrome, sleep apnea, hypertension, and thromboembolic disorders37, 43-45. A.2.2. Assessment for sleep apnea and other conditions that could affect health during pregnancy, including those of the cardiac, pulmonary, renal, endocrine, and skin systems is warranted in the preconception period. Conditional Obesity influences many body systems. The preconception period is an ideal time to assess and manage conditions that could influence the health of the mother and fetus during pregnancy25, 43. According to the Society of Obstetricians and Gynaecologists of Canada (SOGC), baseline preconception health screening in women with obesity, where available and indicated, could include renal, liver, and thyroid function, lipids, and diabetes screen. Additional considerations include cardiovascular health (e.g. blood pressure, echocardiogram) and pulmonary function tests (including sleep apnea where relevant). For further information see the FIGO position paper on preconception health25. Recommendation A.3. All women with obesity should be encouraged to lose weight through diet and adopting a healthy lifestyle including moderate physical activity. If indicated and available, other weight management interventions might be considered, including bariatric surgery. A.3.1. Weight management strategies prior to pregnancy could include dietary, exercise, medical, and surgical approaches. Diet and exercise are the cornerstone of weight management in preconception and pregnancy. Conditional Women should be encouraged to enter pregnancy with a BMI <30, and ideally in the healthy range36. There is evidence that preconception weight loss, achieved through one or more nonsurgical or surgical interventions, has the potential to improve maternal health and reduce risk of pregnancy complications, even when the weight loss is small43, 46. Losing weight before pregnancy can have positive effects such as the reduced risk of obesity in children and improved fertility8, 47. A realistic target is weight loss generally considered to be 5%–10% of original body weight over a period of 6 months43, 48, 49. Individualized counselling sessions that include dietary modifications for weight loss and optimizing nutritional status, combined with aerobic and strengthening exercises, should be considered as the first-line therapy for the management of obesity before conception46, 49. Diet and lifestyle advice should be practical, implementable, and communicated clearly using plain and simple language50. Techniques such as goal setting, social support, and self-monitoring may support the success of diet and lifestyle interventions for weight loss51. 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 BMIs37. This may be due to reduced diet quality52. Dietary advice for women with obesity before pregnancy should focus on achieving weight loss or preventing further weight gain through nutrient-dense foods, following local dietary practices and guidelines that are appropriate for age, medical history, and other characteristics of the woman e.g. dietary practices, allergies, intolerances, or other specific requirements. The specific foods to recommend will vary depending on national guidance, cultural practices, and other considerations25. Detailed information on diet before conception can be found in the FIGO recommendations on adolescent, preconception, and maternal nutrition38. Due to insufficient safety data, medications and surgery for weight loss are not recommended around the time of conception, though should be considered as part of the management of obesity in women who are planning a pregnancy in the future, especially for those with comorbidities and greater severity obesity33, 44, 53. The degree of weight loss achievable with different interventions varies and practitioners and pregnant women should be aware of this in managing expectations for weight management46. Despite this, health benefits such as improved fertility are likely even with small amounts of weight loss and therefore all weight loss should be encouraged, even when achieving a healthy BMI before pregnancy is not possible47. Finally, factors related to weight management, such as depression, should be considered and addressed where appropriate to support weight loss before conception44. If preconception weight loss interventions include bariatric surgery, where possible, women should wait at least 12–18 months after treatment to conceive54. This is to allow for body weight stabilization and the identification and treatment of any nutritional deficiencies, especially in the case of malabsorptive surgery44, 55. Therefore, appropriate contraceptive advice should be given55. Women after bariatric surgery have been found to have any of a variety of vitamin and mineral deficiencies in pregnancy including vitamins A, C, D, B1, B6, B12, and K, iron, calcium, selenium, and phosphorous56. In fact, long-term periodic screening for vitamin and mineral deficiencies is recommended for women after bariatric surgery along with prescribed multivitamin and mineral supplementation57. In cases of advanced maternal age, a shorter interval after surgery could be considered, including the effect of nutritional and other obesity-related issues that are associated with a reduced time to pregnancy54. Due to the associated complexities of nutritional requirements in addition to the usual preconception needs, where possible women with a history of bariatric surgery should be referred to a dietitian before pregnancy37, 49 Recommendation A.4. All women with obesity should be advised to take at least 0.4 mg (400 μg) and consider up to 5 mg folic acid supplementation daily for at least 1–3 months before conception. A.4.1. Women with a BMI ≥30 wishing to become pregnant should be advised to take a folic acid supplement daily, starting at least 1–3 months before conception and continuing during the first trimester of pregnancy. The dose should be at least 0.4 mg (400 μg) and consideration should be given to higher dose (5 mg) as obesity is a risk factor for neural tube defects. Strong Periconceptional folic acid supplementation reduces the incidence of neural tube defects across resource settings58. While there are some differences within published guidelines, FIGO’s advice is that all women of childbearing age should consume at least 0.4 mg (400 μg) supplementary folic acid a day for at least 1 month before conception, continuing until at least the end of the first trimester of pregnancy, to reduce the risk of neutral tube defects33, 44, 59. Consideration should be given to the potential use of a higher dose (5 mg/d) for women with obesity, for example in those who may have other additional risk factors for neural tube defects, for example pregestational diabetes or family history, in line with local and national guidelines and resources37, 60, 61. Depending on the specific diets of the population, women who could become pregnant or are planning a pregnancy may require additional vitamin and mineral supplements. A daily iodine supplement of 150 mg per day, for example, is recommended by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) for women before conception44. Other guidelines suggest consideration of a daily vitamin D supplement43. Vitamin D supplementation may help ensure women with obesity are replete in Vitamin D; however, there is insufficient evidence to determine whether routine supplementation is required37. Dietary intakes, medical history, and other factors such as sun exposure should be considered. Recommendation B.1. All women should have their weight and height measured and their BMI calculated at the first anetanal visit. Consider ethnic differences. Advise on appropriate gestational weight gain. B.1.1. All pregnant women should have their height and weight measured at their first antenatal visit. This can be used to calculate BMI. Data should be recorded in the medical records. Conditional Weight and height should be measured and recorded at the first antenatal visit37. These measures should be used to calculate BMI. This helps give an indication of the pregnancy risks and management requirements. As outlined previously, prepregnancy or early-pregnancy BMI of ≥30 is considered to indicate obesity, however consideration should be given to the health and other risks for women of Asian ethnicity with lower BMIs30. The frequency of subsequent weight checks should be conducted in line with local policy and practices and in consideration of the individual needs and circumstances of the woman. B.1.2. Approaches to monitor and manage gestational weight gain should be integrated into routine antenatal care practices. Strong Recent evidence illustrates that gestational weight gain is an independent risk factor for adverse health outcomes and that it has a cumulative effect, whereby mothers with obesity who gain excessive weight during pregnancy have the greatest risk of pregnancy complications43, 46, 62, 63. B.1.3. Pregnant women with a BMI ≥30 should be advised to avoid high gestational weight gain. Weight gain should be limited to 5–9 kg. Strong While the amount of gestational weight gain considered “normal” will vary regionally, consider advising pregnant women with obesity and a singleton pregnancy to limit gestational weight gain to approximately 5–9 kg to reduce the risk of adverse pregnancy outcomes43, 45, 64. This is based on the Institute of Medicine guidelines (IOM)65. Weight gain in excess of the IOM guidelines has been shown to increase risk of many pregnancy complications, including macrosomia, and cesarean delivery66. Some research suggests however, that the risk of pregnancy complications may be further reduced by limiting gestational weight gain to lower than 5–9 kg67. In addition, excessive gestational weight gain has been associated with adverse cardiometabolic outcomes in offpring68. The IOM guidelines were developed based on the ethnic diversity in the USA in 1990 and 2009 and outline ranges of acceptable gestational weight gain according to weight definitions that are based on standard BMI cut-offs, used by the WHO65, 69. In the absence of country-specific recommendations based on individual population characteristics and trends, the IOM guidelines are used widely internationally, such as in Brazil, Malawi, Australia, and New Zealand44, 70, 71. The utility of the IOM guidelines for women of Indian and other Asian backgrounds has been questioned, mostly due to the variance in BMI cut-offs used for this group72. Despite this, a recent systematic review found that gestational weight gain in excess of the IOM guidelines in Asian women was associated with adverse maternal and fetal outcomes72. Some Asian countries have their own country-specific guidelines, such as Japan, where national guidelines recommend lower gestational weight gain ranges than the IOM (≤5 kg)73. It is therefore prudent that in the absence of suitable country-specific guidance, the IOM guideline of 5–9 kg gestational weight gain can be used for women with obesity. The classification of obesity should, however, be based on the BMI cut-offs most appropriate to that country. This supports the correct application and interpretation of the guidelines and makes them suitable for widespread use.73-75 Recently, high-quality large-scale randomized controlled trials have reported that lifestyle interventions during pregnancy that include diet and exercise advice and behavior change support can reduce excessive gestational weight gain and the frequency of large-for-gestational-age babies (LIMIT, UPBEAT, PEARS trials)76-78. Lifestyle interventions during pregnancy that include diet and physical activity have also been shown to reduce the risk of pregnancy-induced hypertension, cesarean delivery, and respiratory distress in neonates79. Other interventions incorporating dietary counselling and low glycemic index dietary advice and supervised exercise have shown promise in preventing the transmission of risk factors for childhood obesity77, 80. Recommendation B.2. All women should receive information on diet and lifestyle appropriate to their gestation including nutrient supplements, weight management, and regular physical activity. B.2.1. The mainstay of weight management during pregnancy is diet and exercise. Health professionals should provide general nutrition information and advice on a healthy diet to manage weight during pregnancy. Where resources permit, individual plans for diet and exercise for weight management should be put in place. Conditional Diet and lifestyle interventions are clinically effective in reducing gestational weight gain and preventing pregnancy complications so should be offered to women with obesity. Women with obesity may have a higher prevalence of nutritional inadequacies, and intakes of certain micronutrients have been shown to correlate with BMI81. Dietary advice should therefore emphasize healthy dietary patterns that consist of nutrient-dense foods. This may be characterized by higher intakes of fruit, vegetables, wholegrains