Organophosphorus (OP) pesticides are widely used all over the world and locally. Its toxic effects are reported. However, the effects on the pregnant women and their neonates is not fully addressed. Aim of the work: The detection of the potential effects of OP agricultural exposure on pregnancy outcome. Methods: The study included 100 pregnant women, living at rural areas of Damietta and the Great Cairo Governorates. The study was performed between January 2020 and January 2023. Each woman was clinical evaluated by history taking and physical examination. Factors related to the work included OP exposure and use of safety measures. The pregnancy confirmed by ultrasound at 6-8 weeks of gestation. Any malformation was recognized. Ultrasound was repeated at 12-13 and 19-21 weeks for follow up. Blood samples were drawn at 19-21 weeks of gestation to measure pseudo-choline esterase enzyme activity, then women were categorized into those with normal or reduced values of AChE. Women followed up to the delivery and the detection of major malformation was the primary outcome, while the secondary outcome includes minor malformations, miscarriages, premature births, birth weight, gestational age at delivery, and presence of fetal distress or other neonatal complications. Results: The reduction of activity was reported for 60 women, and it was significantly associated with increased previous abortions (20.0% vs 5.0%) and congenital malformations (15.0% vs 2.5%). The gestational age at delivery, and birth weight, were significantly reduced in women with lower AChE. The neonatal respiratory distress was significantly increased in patients with reduced than normal AChE (26.7% vs 10.0%). The AChE values were significantly and proportionately correlated with gestational age, birth weight and Apgar scores at the first and fifth minutes. Conclusion: OP exposure exerts a potential developmental health hazards on pregnancy outcome, such as reduction of the gestational age, birth weight and increased congenital malformation due to OP exposure