INTERIM UPDATE
ACOG PRACTICE BULLETIN SUMMARY
Clinical Management Guidelines for Obstetrician–Gynecologists
NUMBER 230 (Replaces Practice Bulletin Number 156, December 2015)
For a comprehensive overview of these recommendations, the full-text Scan this QR code
version of this Practice Bulletin is available at http://dx.doi.org/10.1097/ with your smartphone
AOG.0000000000004395. to view the full-text
version of this
Practice Bulletin.
Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the Committee on Practice Bulletins–
Obstetrics with the assistance of Patrick M. Catalano, MD and Gayle Olson Koutrouvelis, MD.
INTERIM UPDATE: The content in this Practice Bulletin has been updated as highlighted (or removed as necessary) to reflect
a limited, focused change to align with ACOG Committee Opinion 828, Indications for Outpatient Antenatal Fetal Surveil-
lance, to provide additional information on cell-free DNA screening in this population, and to provide additional recom-
mendations for pregnant patients with BMI 50 or greater.
Obesity in Pregnancy
Obstetrician–gynecologists are the leading experts in the health care of women, and obesity is the most common
medical condition in women of reproductive age. Obesity in women is such a common condition that the implications
relative to pregnancy often are unrecognized, overlooked, or ignored because of the lack of specific evidence-based
treatment options. The management of obesity requires long-term approaches ranging from population-based public
health and economic initiatives to individual nutritional, behavioral, or surgical interventions. Therefore, an under-
standing of the management of obesity during pregnancy is essential, and management should begin before pregnancy
and continue through the postpartum period. Although the care of the obese woman during pregnancy requires the
involvement of the obstetrician or other obstetric care professional, additional health care professionals, such as
nutritionists, can offer specific expertise related to management depending on the comfort level of the obstetric care
professional. The purpose of this Practice Bulletin is to offer an integrated approach to the management of obesity in
women of reproductive age who are planning a pregnancy.
Clinical Management Questions
< Are there interventions for the management of obesity before and during pregnancy?
< What are the recommendations for weight gain in pregnancy for overweight and obese women?
< How should antepartum care be altered for the obese patient?
< How might intrapartum care be altered for the obese patient?
< What are the operative and perioperative considerations in labor and delivery for the obese patient?
< How should postpartum care be altered for the obese patient?
VOL. 137, NO. 6, JUNE 2021 OBSTETRICS & GYNECOLOGY 1137
© 2021 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
< What are effective postpartum care and interpregnancy strategies for weight loss before the next
pregnancy?
Recommendations < Early pregnancy screening for glucose intolerance
(gestational diabetes or overt diabetes) should be
based on risk factors, including maternal BMI of 30
The following recommendations are based on good or
or greater, known impaired glucose metabolism, or
consistent scientific evidence (Level A):
previous gestational diabetes.
< Body mass index calculated at the first prenatal visit < For patients with prepregnancy BMI of 35.0–39.9,
should be used to provide diet and exercise coun- weekly antenatal fetal surveillance may be considered
seling guided by IOM recommendations for gesta- beginning by 37 0/7 weeks of gestation. For patients
tional weight gain during pregnancy. with prepregnancy BMI 40, or greater weekly ante-
< Subcutaneous drains increase the risk of postpartum natal fetal surveillance may be considered beginning
cesarean wound complications and should not be at 34 0/7 weeks of gestation.
used routinely. < Consultation with anesthesia service should be con-
< Clinicians should encourage behavioral interventions sidered for obese pregnant women with OSA because
focused on improving both diet and exercise, which they are at an increased risk of hypoxemia, hyper-
have been shown to improve outcomes compared to capnia, and sudden death.
programs focused on exercise alone.
The following recommendations are based on limited or
inconsistent scientific evidence (Level B):
< Because even small weight reductions before preg- Studies were reviewed and evaluated for quality
nancy in women with obesity may be associated with according to the method outlined by the U.S.
improved pregnancy outcomes, weight loss before Preventive Services Task Force. Based on the highest
pregnancy should be encouraged. level of evidence found in the data, recommendations are
provided and graded according to the following
< Allowing a longer first stage of labor before per- categories:
forming cesarean delivery for labor arrest should be
Level A—Recommendations are based on good and
considered in obese women. consistent scientific evidence.
< Mechanical thromboprophylaxis is recommended Level B—Recommendations are based on limited or
before cesarean delivery, if possible, as well as after inconsistent scientific evidence.
cesarean delivery. Level C—Recommendations are based primarily on
< Weight-based dosage for venous thromboembolism consensus and expert opinion.
thromboprophylaxis may be considered rather than
BMI-stratified dosage strategies in class III obese Full-text document published online on May 20, 2021.
women after cesarean delivery.
Copyright 2021 by the American College of Obstetricians and
< All women with obesity should be provided and Gynecologists. All rights reserved. No part of this publication
referred to behavioral counseling interventions may be reproduced, stored in a retrieval system, posted on the
focused on improving healthy diet and exercise in Internet, or transmitted, in any form or by any means, elec-
order to achieve a healthier weight before another tronic, mechanical, photocopying, recording, or otherwise,
without prior written permission from the publisher.
pregnancy.
The following recommendations are based primarily on American College of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC 20024-2188
consensus and expert opinion (Level C):
Official Citation
< Obese women should be counseled about the limita- Obesity in pregnancy. ACOG Practice Bulletin No. 230.
tions of ultrasound in identifying structural American College of Obstetricians and Gynecologists. Obstet
anomalies. Gynecol 2021;137:e128–44.
1138 Practice Bulletin No. 230 Summary OBSTETRICS & GYNECOLOGY
© 2021 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use
of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of
care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the
treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such
course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or
technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its
publications may not reflect the most recent evidence. Any updates to this document can be found on acog.org or by calling
the ACOG Resource Center.
While ACOG makes every effort to present accurate and reliable information, this publication is provided "as is" without any
warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the
products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents
will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential
damages, incurred in connection with this publication or reliance on the information presented.
All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published
product. Any potential conflicts have been considered and managed in accordance with ACOG’s Conflict of Interest Disclosure
Policy. The ACOG policies can be found on acog.org. For products jointly developed with other organizations, conflict of interest
disclosures by representatives of the other organizations are addressed by those organizations. The American College of
Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the
content of this published product.
VOL. 137, NO. 6, JUNE 2021 Practice Bulletin No. 230 Summary 1139
© 2021 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
