OpenMFM / Clinical Review / 01

GLP-1 Receptor Agonists in Pregnancy

An MFM Clinical Review

Evidence, preconception planning, and counseling after inadvertent exposure

Avoid planned pregnancy exposure; counsel cautiously after inadvertent exposure.

Selected evidence review · October 2026 · 16 slides

Presenter notes

This educational presentation is adapted from the supplied clinical review and approved Canva deck. It is a selected evidence review, not an exhaustive systematic search. Tirzepatide is a dual GIP/GLP-1 agonist; evidence differs between agents.

OpenMFM / Clinical Review / 02

Three clinical questions

Prescribe during pregnancy?

Not recommended.

Accidental early exposure?

Available human data are cautiously reassuring; residual risk remains uncertain.

Termination or amniocentesis?

Exposure alone is not an indication. This is clinical interpretation, not proof of safety.

Presenter notes

Distinguish guidance about planned treatment from counseling after inadvertent exposure. Individualize counseling to the medication, exposure timing, metabolic disease, and patient preferences.

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Current practice guidance

ADA 2026

Discontinue GLP-1 and dual GIP/GLP-1 agonists before pregnancy.

Endocrine Society / ESE 2025

Suggest preconception discontinuation in type 2 diabetes. Conditional recommendation; very-low-certainty evidence.

Pair discontinuation with an active transition plan to avoid hyperglycemia.

Presenter notes

Guideline recommendations support stopping before conception. Timely initiation and titration of alternative antihyperglycemic treatment are essential; do not create a treatment gap.

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Match the plan to the indication

Clinical situation	Recommended approach
Planning conception	Stop before conception; establish pregnancy-compatible management.
Pregnancy recognized	Discontinue promptly; review metabolic treatment.
Preexisting type 2 diabetes	Generally transition to insulin under clinical supervision.
Obesity without diabetes	Stop weight-loss pharmacotherapy; support adequate nutrition and appropriate gestational weight gain.
Gestational diabetes	GLP-1 therapy is not recommended.

Presenter notes

These actions are a clinical synthesis. Individualize treatment with the treating team, including monitoring after medication changes.

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Human evidence: cautiously reassuring

>40,000

exposed pregnancies across seven cohort studies

Uysal et al. · Scientific Reports · July 8, 2026

Observational evidence · Low certainty

Most data address periconception or early exposure. They do not establish safety of continued therapy throughout gestation.

Presenter notes

Cohorts vary in agents, indications, comparators, and exposure windows. Large pooled numbers do not mean equally strong evidence for each individual medication.

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Malformation estimates

Any congenital malformation

OR 1.11
95% CI 0.82–1.51

Major malformations: first trimester

OR 1.39
95% CI 0.73–2.65

Both confidence intervals cross 1. The major-malformation interval still allows a clinically important increase.

Presenter notes

Nonsignificance does not establish equivalence or prove safety. Odds ratios cannot be converted to absolute risks without an appropriate baseline risk. The two estimates have different outcome and exposure definitions.

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Other outcomes and limits

No statistically significant pooled increase

Spontaneous abortion, stillbirth, preterm birth, or small-for-gestational-age birth.

Signal requiring investigation

Urinary malformations were associated with exposure in unadjusted estimates.

Diabetes, obesity, glycemic control, and exposure timing limit causal inference.

Presenter notes

The urinary-malformation signal may reflect residual confounding. Do not interpret observational associations as causal protection or harm, or extrapolate early-exposure results to ongoing use.

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Plan agent-specific discontinuation

Medication	Preconception consideration
Semaglutide · Ozempic / Wegovy / Rybelsus	Stop at least 2 months before planned pregnancy.
Tirzepatide · Mounjaro / Zepbound	Canadian labeling: at least 1 month. US label does not specify an interval; most drug elimination takes about 30 days on average.
Liraglutide	Stop before conception; shorter elimination than weekly agents.
Dulaglutide	Stop before conception; individualize timing.
Exenatide	Stop before conception; formulation matters.

Check current local product labeling. Tirzepatide is a dual GIP/GLP-1 agonist.

Presenter notes

Drug elimination is not the same as a validated safe conception interval. Allow time to establish glycemic control on pregnancy-compatible treatment. Formulation and jurisdiction affect recommendations.

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Tirzepatide and contraception

Oral hormonal contraception may be less effective because absorption can be altered.

Starting treatment

Nonoral contraception or an added barrier method for 4 weeks after initiation.

Each dose escalation

Use the same additional protection for 4 weeks after every dose increase.

This is tirzepatide-specific product-label guidance.

Presenter notes

MotherToBaby summarizes product-label recommendations. Discuss nonoral and barrier options in a patient-centered way. Do not extrapolate this interaction to all GLP-1 agents.

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After inadvertent exposure

Document: drug, dose, indication, last dose, and gestational timing.
Assess diabetes: HbA1c and glucose readings when diabetes is present.
Assess nutrition: nausea/vomiting, hydration, and dietary intake.
Plan: indicated fetal evaluation and individualized follow-up.

Stop the medication and establish alternative treatment promptly with the treating team.

Presenter notes

Characterize whether administration continued after pregnancy recognition. Clinical synthesis: exposure counseling and management of underlying metabolic disease are both essential.

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Fetal assessment after exposure

Detailed anatomical ultrasound at approximately 18–22 weeks.
Fetal echocardiography when indicated by pregestational diabetes or other established risks.
Growth surveillance based on maternal or fetal indications.
Amniocentesis is not indicated solely for GLP-1 exposure.

No validated GLP-1-specific antenatal surveillance protocol.

Presenter notes

Clinical approach after exposure, not a formal graded recommendation. Imaging and surveillance should reflect established indications; GLP-1 exposure alone is not a reason for invasive genetic testing.

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Protect maternal metabolic health

Cessation may bring

Hyperglycemia, increased appetite, and weight regain.

Active clinical response

Review glucose, transition or titrate therapy, and coordinate MFM, diabetes care, and nutrition.

Poorly controlled pregestational diabetes is an established fetal risk.

Presenter notes

The established risks of maternal hyperglycemia require active management while uncertain medication-exposure risks are discussed. Follow glucose readings after discontinuation and adjust treatment.

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A patient counseling example

We recommend avoiding these medications during pregnancy because fetal safety is not established. Available studies are reassuring after accidental early exposure but cannot rule out every risk. We will stop the medication, review your glucose and nutrition, and arrange appropriate fetal assessment.

Individualize counseling; tirzepatide-specific human pregnancy data remain limited.

Presenter notes

Paraphrased example, not a quotation from a guideline. Tailor to the agent, dose, timing, indication, metabolic health, and patient preferences. Do not claim medication-specific safety based only on class-level evidence.

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Questions the evidence cannot yet answer

Do individual agents carry different fetal risks?
What happens with exposure beyond organogenesis?
Are placental development and fetal growth affected?
How do preconception metabolic improvements compare with rebound after withdrawal?

Observational associations do not establish benefit from treatment during pregnancy.

Presenter notes

These are research gaps. Current findings do not justify initiating or continuing GLP-1 therapy during pregnancy for presumed maternal or fetal benefit.

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Take-home clinical checklist

Prevent planned pregnancy exposure.
Use agent-specific washout and contraception guidance.
After accidental exposure: document timing; assess glucose and nutrition.
Plan anatomy imaging and other surveillance for established indications.
Communicate cautious reassurance and uncertainty.

Reassuring early-exposure evidence does not establish safety for ongoing pregnancy use.

Presenter notes

Central takeaway: avoid planned exposure, establish alternative metabolic management, and counsel cautiously after inadvertent early exposure.

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Selected references

Educational clinical review · Individualized clinical judgment required

Open the original Canva presentation ↗

Presenter notes

Selected references and original Canva presentation. This resource supports education and individualized clinical discussion. It does not replace current product labeling, guidelines, or clinical judgment.