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

1UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland 2Institute of Developmental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK 3NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK 4Maternal‐Fetal Medicine Unit, Rabin Medical Center, Petach‐Tikva, Israel 5Sackler Faculty of Medicine, Tel Aviv University, Tel‐Aviv, Israel 6Mater Research, The University of Queensland, South Brisbane, Qld, Australia 7World Diabetes Foundation, Bagsværd, Denmark 8African Federation of Obstetricians and Gynaecologists, Khartoum, Sudan 9Department of Obstetrics and Gynecology, School of Medicine, University of Nairobi, Nairobi, Kenya 10Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China 11Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China 12Divakars Speciality Hospital, Bengaluru, India 13Mor Comprehensive Women’s Health Care Center, Tel Aviv, Israel 14FIGO Pregnancy and Non‐Communicable Diseases Committee, International Federation of Gynecology and Obstetrics, London, UK

T A B L E 3 Good clinical practice recommendations for pregnancy obesity (timepoint B)

| Significance of obesity in women before, during, and after pregnancy
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 obesity 2 . 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 trimester 4 . 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 child 1 .
Obesity increases the risk of noncommunicable diseases (NCDs), such as type 2 diabetes and cardiovascular disease, which contribute to over 70% of global deaths annually 5,6 . This is especially important in LMICs where 86% of premature NCD deaths occur 7 . 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 factors 8 . 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 months 9,10 .
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-gestationalage babies, and metabolic compromise in the offspring [11][12][13][14]  Mechanical thromboprophylaxis is recommended before and after cesarean delivery. Where available, women with a BMI ≥35 should be given graduated compression stockings, or other interventions such as sequential compression devices, after cesarean delivery until mobilization, which should be encouraged early.
T A B L E 4 Good clinical practice recommendations for postpartum obesity (timepoint C)

Recommendation Strength
Obesity is associated with low breastfeeding initiation and maintenance. Women with obesity in early pregnancy should receive specialist advice on the benefits of breastfeeding and appropriate antenatal and postnatal support for breastfeeding initiation and maintenance.

C.2.1
Women with obesity who have been diagnosed with gestational diabetes and other pregnancy complications should have appropriate postnatal follow-up.
Due to the increased risk associated with obesity, where available, women with obesity should be screened for postpartum mental health disorders such as depression and anxiety.
Women should be informed that weight loss between pregnancies reduces the risk of stillbirth, hypertensive complications, and fetal macrosomia in subsequent pregnancies. Weight loss increases the chances of successful vaginal birth after cesarean delivery.
Women with obesity should be offered further dietary and physical activity advice to support postpartum weight management.
Women with obesity should be counselled on the most appropriate form of postnatal contraception based on BMI.
Conditional + + mothers is also associated with immediate adverse outcomes such as stillbirth with risk increasing with higher maternal BMI 17 . Finally, maternal obesity places women at a higher risk of infertility 18 . 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 fertility 19,20 .

| Role of healthcare professionals in obesity management
The causes of maternal obesity are multifaceted, including soci-

| FIGO guidance for the management of prepregnancy, pregnancy, and postpartum obesity
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.  28 . 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.

| Target audience
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 phy-  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 throughout 33 .

| Identification of recommendations and evidence grading
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 pub-

Conditional +
Women should be encouraged to enter pregnancy with a BMI <30, and ideally in the healthy range 36 . 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 small 43,46 .
T A B L E 5 Interpretation of strong and conditional (weak) recommendations according to GRADE. a,b Implications 1 = Strong recommendation phrased as "we recommend"

= Conditional (weak) recommendation phrased as "we suggest"
For patients Nearly all patients in this situation would accept the recommended course of action. Formal decision aids are not needed to help patients make decisions consistent with their values and preferences

Most patients in this situation would accept the suggested course of action
For clinicians According to the guidelines, performance of the recommended action could be used as a quality criterion or performance indicator Decision aids may help patients make a management decision consistent with their values and preferences Both caregivers and care recipients need to be involved in the decision-making process before adopting recommendations.
T A B L E 6 Interpretation of quality of evidence levels according to GRADE. a

Level of evidence Definition
High + + + + We are very confident that the true effect corresponds to that of the estimated effect We are moderately confident in the estimated effect. The true effect is generally close to the estimated effect, but it may be slightly different Low + + Our confidence in the estimated effect is limited. The true effect could be substantially different from the estimated effect Losing weight before pregnancy can have positive effects such as the reduced risk of obesity in children and improved fertility 8,47 .
A realistic target is weight loss generally considered to be 5%-10% 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 outcomes 43,45,64 . 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 delivery 66 . Some research suggests however, that the risk of pregnancy complications may be further reduced by limiting gestational weight gain to lower than 5-9 kg 67 . In addition, excessive gestational weight gain has been associated with adverse cardiometabolic outcomes in offpring 68 . 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][74][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][77][78] .
Lifestyle interventions during pregnancy that include diet and physical activity have also been shown to reduce the risk of pregnancyinduced hypertension, cesarean delivery, and respiratory distress in  Although physical activity may help reduce excessive gestational weight gain, it is also associated with improved outcomes such as gestational diabetes and mode of delivery, independent of gestational weight gain 90    To reduce the risk of intrauterine death, induction of labor should be considered at 41 +0 weeks of gestation for women with a BMI ≥35 86 .
Decisions regarding induction or elective cesarean delivery should be made through individual discussion with the woman, taking her specific clinical and other considerations into account 37 . Induction of labor could also be considered in the case of suspected macrosomia as it associated with lower birth weight and fewer cases of shoulder dystocia or fractures 37,131 .
B.4.11. Women with a BMI ≥40 should be referred to an anesthetist for assessment in the antenatal period.

Conditional +
Anesthetic management of women with obesity may be more challenging and associated with higher risk due to increases in anesthetic time, issues with epidural insertion, and higher incidence of outcomes such as hypotension, heart rate decelerations, and airway intubation 103,132 . Additional concerns based on the medical history of the mother may further complicate anesthetic management as is the case for obstructive sleep apnea, which increases the risk of adverse respiratory outcomes and sudden death 43  with a BMI ≥40 37,44,46,103,104,[113][114][115] . Postoperatively, continuing prophylactic treatment until the woman is mobile is suggested, however the optimal length of treatment is unknown and one should follow local guidance 103,143 .
B.4.18. Mechanical thromboprophylaxis is recommended before and after cesarean delivery. Women with a BMI ≥35 should be given graduated compression stockings, or other interventions such as sequential compression devices, after cesarean delivery until mobilization, which should be encouraged early.

Conditional + +
Women with a BMI ≥35 should be given graduated compression stockings, or other interventions such as sequential compression devices, in addition to low molecular weight heparin after cesarean delivery and until mobilization, which should be encouraged early 37,86 .

| FIGO GUIDANCE FOR POSTPARTUM OBESITY
Recommendation C.1. All women with prepregnancy obesity should receive specialist support on breastfeeding initiation and maintenance.

Conditional +
There is evidence that postpartum weight retention is mostly related to dietary intake rather than energy expenditure 156 .
Interventions involving a combination of diet and physical activity therefore may be more effective than physical activity alone 46,157 .
Women with obesity should be offered personalized nutritional advice for weight reduction in the postpartum period from an appropriately trained professional as the first line in weight management 37,44

| ETHICAL CONSIDERATIONS FOR OBESITY MANAGEMENT
The terms "obese" and "obesity" may be received negatively by patients due to the associated weight-related stigma that is commonly experienced by people with obesity in society, including healthcare settings 44,163,164 . Stigmatization about weight can negatively influence mood, self-esteem, and weight-related behaviors, including food intake and physical activity. Experience of such stigmatization is associated with increased obesity, weight gain, and inflammation, ultimately influencing mortality and other outcomes 163 . Obstetricians and gynecologists should consider their individual bias toward women with obesity and take steps to address this so that they can offer the same respectful clinical care that women with lower BMIs receive 164 .
It is unethical for clinicians in obstetrics and gynecology to decline to care for women who are otherwise within their scope of practice to manage, based solely on their BMI. If available however, referring to clinicians or clinical services with experience and capability in managing women with obesity may be appropriate 164 .
Many patients may identify with the concept of obesity as a disease process and as such, prefer "people-first language", as encouraged by the American College of Obstetricians and Gynecologists (ACOG) and used in other areas of health care including oncology 164 .
Others, however, may disagree with this label and prefer the "health at every size" approach 165 . Obstetricians and gynecologists regularly see women with obesity owing to its high prevalence in many populations internationally. Therefore, clinicians caring for women with obesity before, during, and after pregnancy should consider the impact of their language on the individual. This document has been prepared in line with ACOG recommendations although obstetricians and gynecologists should consider the individual views and needs of the women they care for and adapt their language appropriately.

| A PRAGMATIC APPROACH TO OBESITY MANAGEMENT IN WOMEN WITH PREPREGNANCY, PREGNANCY, AND POSTPARTUM OBESITY
The aim of this guidance on the management of prepregnancy, pregnancy, and postpartum obesity was to review the work of Nonetheless, BMI is a simple-to-measure indicator that can be measured by a variety of trained staff and is therefore appropriate for use in a variety of clinical and other settings. A limitation of this review is that all of the clinical practice guidelines eligible to contribute to the key evidence-based and graded clinical recommendations come from high-income countries. This is because although other clinical practice guidelines exist, the evidence behind the outlined recommendations was not graded or the guidelines were not specific to this topic. Therefore, some of the advice throughout this article may not be applicable or possible to undertake in lower-resource settings. Efforts were made to reference a broad range of international studies, where appropriate, and the corresponding international guidelines. We hope that by summarizing the available work of FIGO member organizations to date, in such a way, that LMICs can use this as a framework for the localization and adaptation of key clinical considerations for women with obesity before, during, and after pregnancy. There is also a clear need for further widespread research on the consequences and management strategies of obesity for women before, during, and after pregnancy in LMICs.

| SUMMARY
Managing obesity before, during, and after pregnancy may have widespread short-and long-term benefits for mothers and their children. By addressing nutrition and weight with women of reproductive age, outcomes can be improved and the burden on healthcare systems reduced.
The transgenerational effect of addressing weight with women is important to address the global burden of NCDs, which we argue are in fact communicable through the passage of risk from mother to child, across generations. This includes cardiometabolic diseases, respiratory diseases, and mental health conditions. Managing obesity will support the achievement of the UN Sustainable Development Goals and the promotion of population health, taking a life course approach to health promotion.
As outlined, obesity management may include a variety of interventions from healthy diets, physical activity, and other medical or surgical options. Diet and lifestyle are the cornerstone of obesity management and while the degree of weight loss achieved with each intervention may vary, healthy diets and lifestyles should be encouraged and can further support additional interventions where employed. Even small amounts of weight loss may have positive effects on some pregnancy and other longterm outcomes. During pregnancy, healthy diets and lifestyle can support management of gestational weight gain. Outside of weight management, women with obesity require specific considerations for medical, surgical, and other care planning and these are outlined in this review. While our objective was to formulate recommendations for the management of maternal obesity, the advice is a guide only and may not apply to all settings. The specific recommendations that are applicable to individual women or within resource settings may vary. Regardless of resource setting, we emphasize that clinicians consider obesity in all women of reproductive age before, during, and after pregnancy and advocate for healthy lifestyles for parents and offspring.

AUTHOR CONTRIBUTIONS
FMcA and SLK wrote the manuscript with contributions from all other authors. EH and SLK translated the evidence and recommendation grading for the review, based on the previously published clinical practice guidelines. All authors contributed to and reviewed the final manuscript.

DISCLAIMER
Clinical judgement is paramount in decision making for the care of women with obesity before, during, and after pregnancy. Any recommendations outlined in this document should be considered in the context of the specific patient case. This advice must also be considered