Bring a large pot of salted water to a boil. Add fettuccine pasta and cook until al dente, about 8 to 10 minutes. Reserve ½ cup of pasta water, then drain and set aside.

In a skillet, heat olive oil over medium heat. Add minced garlic and sauté for 1 minute until fragrant.

Stir in pumpkin puree and cook for 2-3 minutes to combine flavors.

Lower heat and pour in heavy cream, simmer for 3-4 minutes until slightly thickened. Stir in Parmesan cheese, salt, black pepper, and nutmeg.

Fold in chopped sage and cook for an additional 1-2 minutes.

Add drained fettuccine to the sauce, gently tossing to coat. Gradually add reserved pasta water to reach desired consistency.

Plate immediately and garnish with additional Parmesan and fresh sage.