Background <p>Pre-eclampsia is a major cause of maternal and fetal complications in Pakistan, particularly among primigravidas, where poor nutritional status further increases risk. Emerging evidence suggests that underweight pre-eclamptic women may have distinct cardio metabolic adaptations, higher susceptibility to adverse pregnancy outcomes, and increased long-term cardiovascular risk. Lipid-based nutritional supplementation provides essential energy and micronutrients and may help improve maternal metabolic status and pregnancy outcomes in pre-eclamptic women.</p> Objective <p>To determine the effect of lipid-based micronutrient supplementation on lipid profile, Insulin resistance and blood pressure in underweight pre-eclamptic primigravidas at delivery, six months and twelve months postnatal.</p> Methods <p>An open label randomized controlled trial was undertaken to explore the effects of supplementation on the cardio metabolic risk factors in the tertiary care hospitals of KPK, Pakistan. A total of sixty primigravidas were randomized equally into two groups; Group A: control group and Group B; supplement group. At delivery, 26 and 28 participants in Groups A and B, respectively and at 6 and 12 months, 23 and 25 participants were analyzed. In addition to their prescribed antenatal treatment of preeclampsia and IFA (60&#xa0;mg iron and 400ug FA) daily, the Group B also received one 75gm of lipid-based nutrition supplement (LNS) sachet (MAAMTA) daily from their first antenatal visit after enrollment till one year postnatally. The IFA was stopped 6 weeks after delivery.</p> Results <p>There was no discernable difference among the baseline cardio-metabolic parameters like insulin, glucose &amp; HOMA-IR of two groups at delivery. Also, the difference in BP (systolic) was non-significant while BP (diastolic) was decreased in group B (<i>p</i> = 0.025). Similarly, at delivery the significant declined were observed in triglyceride (TGs) levels with LNS supplementation (<i>p</i> = 0.007), Total cholesterol (<i>p</i> = 0.01), LDL (<i>p</i> = 0.02) and VLDL (<i>p</i> = 0.005). At 6 months follow-up systolic (<i>p</i> = 0.002) and diastolic blood pressure (<i>p</i> = 0.013) were decreased significantly in group B &amp; also a significant decline in TGs (<i>p</i> = 0.05), cholesterol (<i>p</i> &lt; 0.001), LDL (<i>p</i> &lt; 0.001) and VLDL levels (<i>p</i> = 0.04) observed in group B. A significant decrease was seen in cholesterol levels (<i>p</i> &lt; 0.001) and LDL levels (<i>p</i> &lt; 0.001) in group B at 12 months postnatal.</p> Conclusion <p>This study concludes that long term LNS supplementation can cause a decrease in cholesterol, TGs, LDL and VLDL in underweight pre-eclamptic primigravidas and thus may contribute to a more favorable cardio metabolic risk profile.</p> Trial registration <p>ClinicalTrials.gov Identifier: ISRCTN 15485068. Registered on April 21, 2018: <a href="https://doi.org/10.1186/ISRCTN15485068">https://doi.org/10.1186/ISRCTN15485068</a>.</p>