Clinical Commander

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endo.gestational-diabetes.chronic.v1

Gestational diabetes (GDM)

obstetricschronicpregnancyadultoutpatientinpatient
Start encounter →Print handoutPRODUCTION

Manifest is a batch-23 scaffold (defineBatch23ScaffoldManifest); no _design-brief.md or atoms.* on disk for this package. Terminology codes (ICD-10 O24.* / SNOMED 237599002 GDM / LOINC OGTT 14743-9, glucose tolerance) chosen from standard pregnancy DM classifications — manifest itself is sparse. Regimen builder authored: insulin-preferred → metformin alternative ladder; glyburide NOT recommended per ACOG 190. Calculator inventory still thin — IADPSG / Carpenter-Coustan threshold calculators, macrosomia risk calc, IOM weight-gain tracker absent from CLINICAL_TOOLS_REGISTRY (gap logged in docs/framework-audit/content-factory/ob-peds.md §1.4). DEEPENING 2026-05-13: (1) Added inpatient L&D setting playbook (previously only outpatient); (2) Added transitions field covering outpatient→inpatient (delivery), outpatient→ed (severe deteriorations), inpatient→outpatient (discharge), inpatient→outpatient (reclassification to overt DM); (3) Added calc.bsa for BMI/weight-gain trajectory. 2026-05-22 citation remediation — the earlier off-topic placeholder PMIDs were already stripped; the named-trial placeholders are now resolved to live-verified PMIDs: 29370047 (ACOG PB 190), 39651985 (ADA Standards of Care in Pregnancy 2025), 15951574 (ACHOIS), 19797280 (Landon MFMU), 18463375 (HAPO), 18463376 (MIG). PEDS DOSING SAFETY: GDM has no peds-specific dosing axes; intrapartum insulin infusion is maternal-only.

Entry points (3)

  • lab_abnormality
    Positive 50g GCT or 75g/100g OGTT (24-28 wk) (ACOG 190 2018; ADA 2026 §15)
    gdm_screen_positive
  • problem_list
    Routine 24-28 wk universal screening (ACOG 190 2018; ADA 2026 §15)
    pregnancy
  • lab_abnormality
    Early-pregnancy A1c ≥6.5% / FPG ≥126 (overt DM in pregnancy) (ADA 2026 §15)
    early_pregnancy_hyperglycemia

Required inputs (9)

  • gestational_agerequired
    demographic • used at CONTEXT
    Screening (24-28 wk), delivery timing, fetal monitoring intensity (ACOG 190 2018)
  • maternal_agerequired
    demographic • used at CONTEXT
    Risk stratification; advanced maternal age modifier (ADA 2026 §15)
  • pre_pregnancy_bmirequired
    vital • used at CONTEXT
    Pre-pregnancy BMI gates risk + weight-gain target (ACOG 190 2018)
  • fasting_glucoserequired
    lab • used at INITIAL_WORKUP
    Diagnostic threshold (one-step ≥92, two-step varies) (IADPSG; Metzger NEJM 2008)
  • ogtt_2hrequired
    lab • used at INITIAL_WORKUP
    75g IADPSG one-step or 100g Carpenter-Coustan two-step (ACOG 190 2018; ADA 2026 §15)
  • a1c
    lab • used at INITIAL_WORKUP
    Distinguishes overt pre-existing DM from GDM in early pregnancy (ADA 2026 §15)
  • prior_gdmrequired
    history • used at CONTEXT
    ~50% recurrence; earlier screen at 6-12 wk (ADA 2026 §15)
  • pcos
    history • used at CONTEXT
    Pre-pregnancy insulin resistance increases GDM risk (ADA 2026 §15)
  • family_history_dm
    history • used at CONTEXT
    First-degree relative T2DM raises baseline risk (ADA 2026 §15)

12-phase flow (10)

  1. 1FRAME
    Distinguish GDM (new in pregnancy) from overt pre-existing DM (A1c ≥6.5% in early pregnancy → manage as pregestational DM) (ADA 2026 §15)
    inputs: gestational_age, a1c
    advance: GDM vs overt DM classification made
  2. 2ENTRY
    Capture screening trigger (universal 24-28 wk) or risk-based early screen (ACOG 190 2018)
    inputs: gestational_age, maternal_age
    advance: screening trigger documented
  3. 3CONTEXT
    Capture pre-pregnancy BMI, prior GDM, PCOS, family history, prior macrosomia, ethnicity, SDOH (ADA 2026 §15; ACOG 190 2018)
    inputs: pre_pregnancy_bmi, prior_gdm, pcos, family_history_dm
    advance: risk profile complete
  4. 4INITIAL_WORKUP
    One-step 75g IADPSG OR two-step 50g GCT then 100g Carpenter-Coustan; FPG; A1c if early; baseline UACR + lipid + TSH (IADPSG; Metzger NEJM 2008; ACOG 190 2018)
    inputs: fasting_glucose, ogtt_2h, a1c
    actions: panel.glucose_a1c
    advance: GDM diagnostic criteria met
  5. 5BRANCHING_WORKUP
    Macrosomia surveillance (growth US 28/32/36 wk); fetal cardiac if A1c >6.5% + early-pregnancy DM; preeclampsia screen overlap (ACOG 190 2018)
    actions: workup.gestational_diabetes
    advance: fetal surveillance plan documented
  6. 6DIFFERENTIAL
    GDM A1 (diet-controlled) vs A2 (medication-requiring); rule out unmasked T2DM (A1c, FPG) (ACOG 190 2018; ADA 2026 §15)
    advance: GDM class assigned (A1 vs A2)
  7. 7TREATMENT
    Medical nutrition therapy (MNT) first-line; insulin preferred (ACOG 190 2018) if not at target; metformin alternative (Rowan NEJM 2008 MIG); glyburide last-line; SGLT2/GLP-1 contraindicated in pregnancy (ADA 2026 §15)
    inputs: fasting_glucose
    advance: MNT instituted; pharmacotherapy added if 1-2 wk lifestyle fails to meet targets (FPG <95, 1h <140, 2h <120)
  8. 8DISPOSITION
    OB/MFM coordination; growth ultrasounds; antepartum testing (NST/BPP); planned delivery 39-40 wk if well-controlled, earlier if poor control or macrosomia (ACOG 190 2018)
    advance: delivery plan set
  9. 9MONITORING
    SMBG QID (fasting + post-prandial), weekly OB review, fetal kick counts; targets FPG <95, 1h PP <140, 2h PP <120 (ACOG 190 2018; ADA 2026 §15)
    inputs: fasting_glucose
    actions: panel.glucose_a1c
    advance: glycemic targets being met or escalation triggered
  10. 10FOLLOWUP
    Postpartum 75g OGTT at 4-12 wk; lifelong T2DM screening q3y; lactation support (reduces future DM); pre-pregnancy planning for next pregnancy; metformin for prevention if prediabetes (ADA 2026 §15; ACOG 190 2018)
    advance: postpartum OGTT scheduled; lifelong follow-up plan made