Key takeaways:
- Available data on inadvertent first-trimester GLP-1 RA exposure have not demonstrated a signal for congenital malformations or teratogenicity, but the absence of a harm signal is not equivalent to established safety; lactation guidance currently rests on shared decision-making given the absence of breast milk data.
- GLP-1 RA-associated weight loss can restore ovulatory function in patients with weight-related infertility, making proactive contraception counseling essential at the time of GLP-1 RA initiation in reproductive-capable individuals—a parallel to established post-bariatric surgery practice.
- Disparities in postpartum GLP-1 RA prescribing by race, ethnicity, insurance type, and geography remain uncharacterized in current datasets and represent a priority research direction as the field moves toward more granular analysis.
As GLP-1 receptor agonist prescribing in the perinatal period continues to rise, the clinical questions that the prescribing trend data cannot answer are becoming increasingly urgent—and the most pressing of those questions falls squarely on the ob-gyn, according to Kevin Y. Xu, MD, MPH, and Jeannie C. Kelly, MD, MS, whose national EHR study1 has been reported in 2 prior installments.
With the prescribing trends and methodologic limitations previously addressed, the investigators turned to what practicing ob-gyns most need to know: what to do when a patient on a GLP-1 RA becomes pregnant, what the data do and do not show about safety, and why non-obstetric prescribers are a critical part of the conversation.
The dataset cannot identify why postpartum patients were prescribed GLP-1 RAs—whether for obesity, type 2 diabetes, or emerging indications—and it contains no lactation data. Kelly noted that comorbidity data from the year prior to delivery show meaningful rates of obesity and diabetes diagnoses in the cohort, and that these conditions frequently persist or emerge postpartum. But the specific clinical indication driving postpartum initiation remains uncharacterized.
"We don't have that indication quite clearly spelled out postpartum or pre-delivery," she said.
For ob-gyns counseling reproductive-age patients currently on GLP-1 RAs, Kelly offered a framework grounded in current guidance and emerging reassurance. The FDA recommendation to discontinue 1 to 2 months before conception and stop immediately upon discovering unplanned pregnancy remains the clinical standard. However, Kelly noted that available data on inadvertent first-trimester exposure have not shown a signal for congenital malformations or teratogenicity.
"We don't really see a harm signal from the data that does exist," she said—while emphasizing that the absence of a harm signal is not the same as established safety. Lactation guidance currently rests on shared decision-making given the absence of breast milk data.
Two underappreciated dimensions of counseling emerged as priorities. The first is patient disclosure.
"Patients may feel ashamed or embarrassed that they're on medications they potentially think they shouldn't be," Kelly said. Creating space for patients to disclose GLP-1 RA use without judgment is a prerequisite for appropriate counseling. The second is the fertility-weight loss interaction. GLP-1 RAs—like bariatric surgery before them—can restore ovulatory function in patients with weight-related infertility.
“If you are not on top of contraception for someone who is experiencing rapid weight loss, even if they were anovulatory prior to the weight loss, they're at very high risk of getting pregnant inadvertently," Kelly said. The parallel to bariatric surgery is instructive: Strong contraception counseling for 1 to 2 years post-procedure is standard practice, and the same logic applies to GLP-1 RA initiation in reproductive-capable individuals.
Kelly also stressed that ob-gyns are not the primary prescribers of these medications and cannot manage perinatal GLP-1 RA exposure in isolation.
"OB/GYNs are not the ones prescribing GLP-1s in the vast majority of cases," she said. Primary care physicians, endocrinologists, psychiatrists—particularly as indications expand to include conditions like substance use disorder—are the clinicians initiating these agents in patients who may subsequently become pregnant. Cross-specialty communication and shared awareness of reproductive implications are essential.
Xu added that disparities in postpartum GLP-1 RA prescribing by race, ethnicity, insurance type, and geography remain entirely uncharacterized in the current dataset—and represent a critical next step.
"That's super important and definitely something many of us and our colleagues are thinking about," he said.
Reference:
1. Lessard C, Cary C, In A, et al. Prescribing Trends in glucagon-like peptide-1 medications among pregnant and postpartum persons. Obstet Gynecol. 2026;147(3):290-292. doi:10.1097/AOG.0000000000006161
