Expectant mothers are simultaneously cautioned by doctors to gain no more than 35 pounds and egged on by friends and family to splurge because they're eating for two.

Few heed the experts.

Now, new guidelines from the national Institute of Medicine are recommending even less weight gain during pregnancy for obese women -- topping out at 20 extra pounds.

It's a bigger issue than vanity. Extra pounds on a woman who is already overweight can cause harm to mother and baby alike, raising the risk of gestational diabetes, hypertension, premature birth and Cesarean sections.

The national advisory group is calling for a better dialogue between doctors and all expectant mothers about what constitutes healthy weight gain.

''There need to be societal changes,'' said Anna Maria Siega-Riz, associate professor of epidemiology and nutrition at the Gillings School of Global Public Health at UNC-Chapel Hill.

Siega-Riz, a member of the Institute of Medicine committee that rewrote Thursday's weight gain recommendations, said the last time guidelines were issued in 1990, fewer women were overweight and obese. Today, she said, half of pregnant women are overweight or obese, defined as a score of 30 or above on a height-weight ratio called the Body Mass Index.

What's more, up to 60 percent of all pregnant women in the United States pack on much more weight than the recommended amount, no matter where they started on the BMI scale.

''I think there's a notion that people want to take care of women who are pregnant -- indulge them,'' said Dr. Alison Stuebe, an assistant professor of obstetrics and gynecology at UNC-Chapel Hill who has studied the health consequences of obesity and pregnancy.

''Some women use pregnancy to eat whatever they want and not feel bad about it,'' Stuebe said. ``Well, eating for two is fun, but losing for two is not.''

Dr. Sarah Maddison, who practices at MidCarolina OB/Gyn in Raleigh, N.C., said even routine progress reports are more difficult in heavier women. Ultrasound scans, fetal heart monitors and other devices can't get precise readings of the fetus if the mother carries a lot of additional weight.

''It's harder to diagnose if the baby gets excessively big, or not big enough,'' Maddison said.

She urges obese patients who are considering pregnancy to lose a few pounds before they conceive.

Amy Hutchinson of Apex, N.C., said she was ''not a skinny Minnie'' before she became pregnant, and has been watching her weight carefully throughout her pregnancy. She said she fears the consequences of a huge weight gain, which she has avoided.

''It has to come off eventually,'' she said.

Often, however, the weight gained during pregnancy stays on, becoming a factor during subsequent pregnancies. Dr. Greg Mohs, an ob-gyn, never recommends that women lose weight while they're pregnant. But he said some obese patients actually benefit from gaining very little, if no weight at all.

''I would rather see a cap at 10 pounds,'' Mohs said of the new weight gain recommendations for obese patients.

But the subject of weight and diet is often difficult to broach. Maddison said many women take offense during discussions about their weight.

''More than any other subject, weight is delicate,'' Maddison said. ``We just try to remind people of the guidelines and what the risks are.''

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