ACOG advises against GLP-1 receptor agonists during pregnancy

The American College of Obstetricians and Gynecologists (ACOG) has issued a practice advisory recommending that ob-gyns counsel patients on the lack of sufficient safety data for glucagon-like peptide-1 receptor agonists (GLP-1RAs) in pregnancy, advise considering discontinuation 1 to 2 months before conception, and advise against use during pregnancy. For lactation, the guidance supports shared decision-making on a postpartum care plan that may include GLP-1RAs, with close surveillance of neonatal weight gain, and recommends against use in individuals breastfeeding or chestfeeding preterm infants and neonates.

Prescribing of GLP-1RAs in the perinatal period increased more than 30- between 2019 and 2024, according to a large retrospective cohort study cited in the advisory. The long half-lives of semaglutide, tirzepatide, and dulaglutide make avoiding the medication during pregnancy more challenging, and because GLP-1RA-associated weight loss may improve fertility, patients who can become pregnant should be counseled on effective contraception.¹

“Currently, as many as 1 in 300 women are exposed to GLP-1s prior to pregnancy,” said D. Yvette LaCoursiere, MD, FACOG, lead author of the guidance, in an ACOG news release. “This is a fast-moving area of research, so for now we need to proceed with caution and reassess as more data becomes available.”²

What do pregnancy outcome data show?

No consistent evidence of congenital anomalies from GLP-1RA use has been reported. Four systematic reviews and meta-analyses of periconceptional and early-pregnancy exposure did not show statistically significant increases in major congenital malformations, spontaneous pregnancy loss, stillbirth, preterm birth, small-for-gestational-age infants, gestational diabetes, hypertensive disorders of pregnancy, or preeclampsia. These analyses drew on a limited number of heterogeneous observational studies with inconsistent adjustment for confounding, and 1 identified a possible association with urinary tract malformations based on unadjusted data. In animal studies, exposure was associated with decreased fetal weight, growth restriction, and ossification abnormalities, according to ACOG.

Findings on prepregnancy use were mixed. A 2025 matched retrospective cohort of more than 4000 individuals per group linked a prepregnancy GLP-1RA prescription with decreased odds of gestational diabetes (18.2% vs 15.2%), hypertensive disorders of pregnancy (22.8% vs 19.9%), preterm delivery (4.4% vs 3.0%), and cesarean delivery (19.7% vs 17.6%), though absolute differences were modest.

In contrast, a retrospective cohort of nearly 150,000 singleton pregnancies found exposure was associated with greater gestational weight gain (mean, 13.7 kg vs 10.5 kg; P < .001) and increased risk of preterm delivery (17% vs 13%; RR, 1.34; 95% CI, 1.06-1.69), gestational diabetes (20% vs 15%; RR, 1.30; 95% CI, 1.01-1.68), and hypertensive disorders of pregnancy (46% vs 36%; RR, 1.29; 95% CI, 1.12-1.49). Controls were matched on prepregnancy BMI rather than BMI at treatment initiation. A separate cohort found no significant differences between individuals with pregnancy exposure and former users, suggesting observed risks may reflect rebound effects after discontinuation rather than intrauterine exposure.¹

Managing weight regain after discontinuation

“While patients often experience the positive effects of GLP-1s prior to pregnancy, there are risks associated with both taking the medication and discontinuing that people should consider,” said Amy Valent, DO, FACOG, chair of ACOG’s Clinical Consensus Committee-Obstetrics. “Unfortunately, regaining lost weight is common and may increase the risk of adverse outcomes linked to obesity and excessive gestational weight gain. Therefore, ACOG encourages clinicians to monitor their patient’s weight and counsel them on incorporating lifestyle interventions such as healthy and diversified eating habits, nutrition referral, regular physical activity, and behavioral support.”²

For patients who used GLP-1RAs before pregnancy, ACOG outlined tailored counseling on exercise and eating patterns, evaluation for nutrient deficiencies such as vitamin D, vitamin B12, and ferritin, dietitian referral when needed, and preeclampsia risk screening with low-dose aspirin when indicated.

Lactation and infant growth

Human milk studies are limited to drug detection and do not assess milk volume, composition, or infant weight gain. Semaglutide was not detected in human milk at 0, 12, and 24 hours after subcutaneous administration. Exenatide, which has the shortest half-life of the GLP-1RAs, would be preferred if indicated, and oral formulations should be avoided during breastfeeding or chestfeeding.¹

For population, ACOG recommends engagement in shared decision-making with patients to create a care plan that could include GLP-1s, though the College recommends against use during lactation for infants within the first 28 days of life and for preterm infants as well.

“While GLP-1s are unlikely to be present in breast milk based on early data, there is not adequate safety data or information on the long-term effects,” said LaCoursiere. “ACOG is recommending that ob-gyns advise lactating patients about these uncertainties. For those who ultimately choose to use GLP-1s despite limited data, it is prudent to select the ones with shorter half-lives and closely monitor their infant’s weight gain.”²

The recommendation against use during pregnancy applies except within the context of a clinical trial, and ACOG called for confirmatory studies and registry surveillance of maternal and neonatal outcomes.

“The American College of Obstetricians and Gynecologists will continue to actively monitor this topic and update this Practice Advisory as needed with additional information,” the advisory stated.¹

References:

1. American College of Obstetricians and Gynecologists. Use of glucagon-like peptide-1 receptor agonists in pregnancy and lactation. Practice Advisory. October 2026. Accessed October 28, 2026. https://www.acog.org/clinical/guidance/practice-advisory/2026/10/use-of-glucagon-like-peptide-1-receptor-agonists-in-pregnancy-and-lactation
2. ACOG releases new guidance on the use of GLP-1s in pregnancy and lactation. News release. American College of Obstetricians and Gynecologists. October 23, 2026. Accessed October 28, 2026. https://www.acog.org/news/2026/10/acog-releases-new-guidance-on-use-of-glp-1s-in-pregnancy-lactation