Clinical Commander

All dossiers
ob.gdm.core.v1

Gestational Diabetes Mellitus (A1 / A2 — OB perspective)

obstetricssubacutechronicadultpregnancyoutpatientinpatient
Start encounter →Print handoutPRODUCTION

New dossier this shard (shard-5-obped-id Phase C, 2026-05-15) — OB-side perspective complement to existing endo.gestational-diabetes.chronic.v1. Manifest pointer set to prisma/seed/manifests/ob.gdm.core.v1.ts (gdmCoreManifest) — the seed manifest exists on disk. During verification 2026-05-25 its hand-authored terminology was found to carry fabricated/mislabeled RxCUIs (5856 + 208679 invalid; 41493 resolved to meloxicam [an NSAID, not insulin detemir]; 274783 = glargine not lispro; 25789 = glimepiride not glyburide; 311026 = an NPH product not regular insulin) and was replaced wholesale with codes projected 1:1 from this (live-verified) dossier. Co-located _briefs/ob.gdm.core.v1.md + _research-bundles/ob.gdm.core.v1.md authored alongside this dossier per §5.5 contract items 1+2. Phenotype matrix encoded via severity_triggers (7 triggers) + setting playbooks (outpatient + inpatient) rather than a first-class TS phenotype field (schema-blocked). Phenotype axes: timing (early-detected first-trimester vs standard 24-28 wk) × class (A1 vs A2) × parity × BMI tier × ethnic risk × fetal load × concurrent comorbidity × delivery timing per delivery-timing consensus (Spong, Obstet Gynecol 2011, PMID 21775849). Severity triggers: early_detected_first_trimester_gdm (severe), a2_gdm_glucose_uncontrolled_despite_insulin (severe), gdm_with_macrosomia_or_polyhydramnios (severe), gdm_with_recurrent_hypoglycemia (severe), gdm_with_superimposed_pre_eclampsia (severe with carryover to ob.pre-eclampsia.core.v1), postpartum_glucose_intolerance (mild with route to endo.dm2.core.v1), dka_in_pregnancy_with_gdm (life-threatening with carryover to endo.dka.core.v1 per Sibai 2014 PMID 24463678). Bayesian linkage (documented in co-located _briefs/ob.gdm.core.v1.md): pre-test priors GDM ~ 6-10% general, ~ 10-15% ethnic high-risk, ~ 18-22% with prior GDM; LR+ 50-g GCT ≥ 140 ~ 2-3 for 100-g OGTT-positive GDM; LR+ HbA1c ≥ 6.5% first-trimester ~ 5-10 for overt DM; LR- HbA1c < 5.7% 0.2 for overt DM; T_treat (A2 transition) = ≥ 50% values exceeding target for 1-2 wk despite MNT; T_test (rule-out) = negative 50-g GCT + no risk factors; cross-dossier routing edges to ob.pre-eclampsia.core.v1 (PE overlap 4-5×), endo.dka.core.v1 (rare DKA-in-pregnancy), endo.dm2.core.v1 (postpartum reclassification if DM). Calculator gaps: IADPSG threshold calc, Carpenter-Coustan threshold calc, gestational A1c target tracker (< 6%), macrosomia risk calc, IOM weight-gain tracker, A2 transition trigger calc — none exist in CLINICAL_TOOLS_REGISTRY today; NEEDS_SOURCE_REVIEW. calc.bsa used for BSA + insulin dosing surrogate. RxCUIs live-verified vs RxNav 2026-05-25 (insulin NPH/isophane 253181, detemir 139825, aspart 51428, lispro 86009, metformin 6809, glyburide 4815, aspirin 1191, betamethasone 1514). NPH corrected from 253182 ("insulin, regular, human" — wrong drug, off-by-one) to 253181 ("insulin isophane, human" = NPH). HAPO and MIG were both published in NEJM 2008 with adjacent PMIDs and were previously conflated; live-verified 2026-05-25: HAPO (Metzger, "Hyperglycemia and adverse pregnancy outcomes") = PMID 18463375; MIG (Rowan, "Metformin versus insulin for the treatment of gestational diabetes") = PMID 18463376. Both now cited as distinct entries. CGM in pregnancy: emerging evidence base — CONCEPTT 2017 (PMID 28923465) in T1DM showed HbA1c -0.19%, LGA 53% vs 69%, OR 0.51; off-label use in GDM lacks dedicated RCT support and is surfaced via severity-trigger rationale rather than as first-line monitoring recommendation. Postpartum reclassification per ADA 2025: normal fasting < 100 + 2-h < 140; IGT fasting 100-125 OR 2-h 140-199; DM fasting ≥ 126 OR 2-h ≥ 200 OR A1c ≥ 6.5%. Lifetime DM2 risk 50-70% per Bellamy meta-analysis Lancet 2009 (PMID 19465232, HR 7.43); DPP-derived intensive lifestyle reduces DM2 by 58% (Knowler NEJM 2002 PMID 11832527, NNT 7 over 2.8 years). Status INTEGRATED (promoted 2026-05-25): non-empty manifest pointer (prisma/seed/manifests/ob.gdm.core.v1.ts) satisfies _completeness.checkScaffolded; workups[] resolves to workup.gestational_diabetes in CLINICAL_TOOLS_REGISTRY; full content (calculator + regimen + test_files + evidence pmids + last_reconciled + CONTEXT/TREATMENT/MONITORING/FOLLOWUP phases). Promotion gated on live-verification of all citations (11 array PMIDs + inline) and RxCUIs — completed 2026-05-25; fabricated PMIDs 34546296/28859943/17392552/28457810/24463687 replaced, NPH RxCUI 253182→253181 corrected.

Entry points (6)

  • demographic
    Pregnancy at 24-28 weeks → universal GDM screening (USPSTF 2021, PMID 34374716; ACOG 190)
    pregnancy_24_28_weeks
  • demographic
    Early pregnancy + high-risk profile (BMI ≥ 30, prior GDM, prior macrosomia, PCOS, ethnic risk, family DM2) → early GDM screen (ACOG 190)
    pregnancy_first_visit_high_risk
  • lab_abnormality
    50-g GCT ≥ 140 mg/dL → proceed to 100-g 3-h OGTT (Carpenter-Coustan or NDDG) (ACOG 190)
    positive_50g_gct
  • lab_abnormality
    75-g 2-h OGTT positive (fasting ≥ 92, 1-h ≥ 180, 2-h ≥ 153) → GDM diagnosis (IADPSG 2010, PMID 20190296)
    positive_75g_iadpsg_ogtt
  • lab_abnormality
    HbA1c ≥ 6.5% in first trimester → overt DM in pregnancy (pre-existing T2DM unmasked) (ADA 2025)
    a1c_first_trimester_ge_6_5
  • history
    Prior GDM (recurrence ~ 60%, Kim Diabetes Care 2007 PMID 17290037) → early screen + counseling
    prior_gdm

Required inputs (19)

  • gestational_agerequired
    demographic • used at FRAME
    Drives screening timing (24-28 wk universal; earlier if high-risk) + delivery timing (A1: 39-40+6 wk; A2: 37-39+6 wk per ACOG 190 + SMFM 2017)
  • pre_pregnancy_bmirequired
    demographic • used at CONTEXT
    BMI ≥ 30 = high-risk indication for early screening (ACOG 190)
  • prior_gdmrequired
    history • used at CONTEXT
    Recurrence ~ 60% (Kim Diabetes Care 2007 PMID 17290037) → early screen + counseling
  • prior_macrosomiarequired
    history • used at CONTEXT
    Prior infant > 4000 g = high-risk indication for early GDM screen (ACOG 190)
  • pcos
    history • used at CONTEXT
    Polycystic ovary syndrome = high-risk indication; insulin resistance substrate (ACOG 190)
  • family_history_dm2
    history • used at CONTEXT
    First-degree relative with DM2 = high-risk indication (ACOG 190)
  • ethnic_high_risk
    history • used at CONTEXT
    Hispanic / Asian / Native American / African American baseline GDM prevalence ~ 10-15% vs general ~ 6-10% (USPSTF 2021)
  • gct_50g
    lab • used at INITIAL_WORKUP
    Two-step screening (most common US): 50-g 1-h glucose challenge; ≥ 140 mg/dL → proceed to 100-g 3-h OGTT (ACOG 190)
  • ogtt_75g_iadpsg
    lab • used at INITIAL_WORKUP
    One-step screening (IADPSG): 75-g 2-h OGTT — fasting ≥ 92, 1-h ≥ 180, 2-h ≥ 153 mg/dL = GDM (IADPSG 2010, PMID 20190296)
  • ogtt_100g_3h
    lab • used at INITIAL_WORKUP
    Two-step confirmatory: 100-g 3-h Carpenter-Coustan (fasting ≥ 95, 1-h ≥ 180, 2-h ≥ 155, 3-h ≥ 140; ≥ 2 abnormal = GDM) per ACOG 190
  • a1crequired
    lab • used at INITIAL_WORKUP
    A1c ≥ 6.5% first trimester → overt DM in pregnancy; trajectory < 6.0% optimal during pregnancy per ADA 2025
  • fasting_glucoserequired
    lab • used at INITIAL_WORKUP
    Fasting glucose ≥ 126 first trimester = overt DM; SMBG fasting < 95 mg/dL target during pregnancy (ACOG 190)
  • smbg_logrequired
    lab • used at MONITORING
    SMBG 4×/day (fasting + 1-h or 2-h postprandial × 3 meals) → drives A1 vs A2 classification (ACOG 190)
  • fetal_growth_usrequired
    imaging • used at MONITORING
    Growth scan q4 wk to detect macrosomia (EFW ≥ 95th %ile) or polyhydramnios (AFI > 24) → drives delivery timing (ACOG 190)
  • nst_or_bpp
    imaging • used at MONITORING
    Weekly NST or BPP from 32 wk for A2 GDM; A1 well-controlled may defer per ACOG 190
  • decreased_fetal_movement
    symptom • used at RED_FLAGS
    Decreased kick counts → urgent NST/BPP + consider delivery (ACOG 190)
  • recurrent_hypoglycemia
    symptom • used at RED_FLAGS
    Recurrent hypoglycemia on insulin → adjust regimen + nutritional reassessment + CGM consideration (ADA 2025)
  • sbprequired
    vital • used at RED_FLAGS
    BP ≥ 140/90 raises superimposed pre-eclampsia concern; GDM increases PE risk 4-5× (HAPO-FUS)
  • current_insulin_or_oha
    medication • used at CONTEXT
    Current insulin regimen / metformin / glyburide status — drives A1 vs A2 classification and titration plan

12-phase flow (12)

  1. 1FRAME
    Confirm pregnancy + screening eligibility (universal 24-28 wk per USPSTF 2021, PMID 34374716; earlier if high-risk per ACOG 190); distinguish GDM from overt DM in pregnancy (pre-existing T1/T2DM unmasked, A1c ≥ 6.5% at conception)
    inputs: gestational_age, pre_pregnancy_bmi
    advance: Screening eligibility assigned + overt-DM differential considered
  2. 2ENTRY
    Universal screening at 24-28 wk; early screening at first prenatal visit for high-risk (BMI ≥ 30, prior GDM, prior macrosomia, PCOS, ethnic risk, family DM2) (ACOG 190; USPSTF 2021)
    inputs: gestational_age
    advance: Screening method selected (one-step IADPSG vs two-step Carpenter-Coustan)
  3. 3CONTEXT
    Capture parity, prior GDM (recurrence ~ 60% per Kim 2007 PMID 17290037), prior macrosomia, PCOS, ethnic risk, family DM2, current pregnancy (singleton vs multiple), concurrent chronic HTN; aspirin status if PE risk (ACOG 190; USPSTF 2021)
    inputs: prior_gdm, prior_macrosomia, pcos, family_history_dm2, ethnic_high_risk, current_insulin_or_oha
    advance: Risk-factor profile documented + screening method + entry trigger captured
  4. 4RED_FLAGS
    DKA in pregnancy (rare but can occur at lower glucose thresholds 200-250 mg/dL per Sibai 2014 PMID 24463678) → route to endo.dka.core.v1; recurrent hypoglycemia on insulin → adjust regimen; superimposed pre-eclampsia (BP ≥ 140/90 + GDM = 4-5× PE risk) → route to ob.pre-eclampsia.core.v1 with carryover
    inputs: sbp, decreased_fetal_movement, recurrent_hypoglycemia
    advance: Red-flag screen complete; DKA/PE/hypoglycemia rule-outs documented
  5. 5INITIAL_WORKUP
    Diagnostic OGTT — one-step 75-g 2-h IADPSG (fasting ≥ 92, 1-h ≥ 180, 2-h ≥ 153) OR two-step (50-g GCT ≥ 140 → 100-g 3-h Carpenter-Coustan: fasting ≥ 95, 1-h ≥ 180, 2-h ≥ 155, 3-h ≥ 140, ≥ 2 abnormal = GDM) per ACOG 190; HbA1c (overt-DM screen ≥ 6.5%); baseline CBC + BMP; urine ketones if hyperglycemic symptoms
    inputs: gct_50g, ogtt_75g_iadpsg, ogtt_100g_3h, a1c, fasting_glucose
    actions: gestational_diabetes, panel.glucose_a1c, panel.cbc
    advance: OGTT result and A1c documented; diagnostic threshold met or excluded
  6. 6BRANCHING_WORKUP
    Early-detected first-trimester GDM (likely pre-existing T2DM; A1c at start + insulin from start; major-malformation US at 18-20 wk) → consider overt DM in pregnancy; A2 GDM with EFW ≥ 95th %ile → growth-scan acceleration + delivery-timing reassessment (ACOG 190)
    inputs: a1c, fetal_growth_us
    advance: Phenotype branch decided (A1 vs A2 vs overt DM; macrosomia overlay if present)
  7. 7DIFFERENTIAL
    Phenotype: A1 GDM (diet-controlled), A2 GDM (medication-required), overt DM in pregnancy (pre-existing T1/T2DM unmasked), impaired glucose tolerance (postpartum reclassification only), normal glucose tolerance (negative OGTT rule-out) (ACOG 190; ADA 2025)
    advance: Phenotype assigned
  8. 8RISK_STRATIFICATION
    A2 transition trigger (≥ 50% values exceeding target at same time-of-day for 1-2 weeks despite MNT); EFW ≥ 95th %ile (macrosomia); AFI > 24 (polyhydramnios); A1c trajectory (< 6.0% optimal per ADA 2025); superimposed PE (ACOG 190; SMFM 2017)
    inputs: smbg_log, fetal_growth_us, a1c, sbp
    actions: calc.bsa
    advance: A1 vs A2 classification + macrosomia overlay + delivery-timing tier decided
  9. 9TREATMENT
    A1: medical nutrition therapy (35-45% carb, 3 meals + 2-3 snacks) + 30 min/d moderate exercise + SMBG 4×/day; A2 first-line = insulin (NPH/detemir basal + lispro/aspart bolus per pattern) per ADA + ACOG 190; metformin/glyburide are alternatives with placenta-crossing caveats (MIG, Rowan NEJM 2008); SGLT2i/GLP-1/DPP-4 contraindicated in pregnancy (ADA 2025)
    inputs: smbg_log, a1c
    advance: Treatment plan assigned (MNT for A1; insulin/metformin for A2) + glucose targets being met or escalation triggered
  10. 10DISPOSITION
    Outpatient prenatal + GDM clinic for stable A1/A2; antenatal floor for inpatient glucose control if uncontrolled A2 or DKA-in-pregnancy (rare); ED for DKA-in-pregnancy or hyperemesis-with-poor-intake-and-hypoglycemia; L&D for delivery; postpartum + endocrine for 6-12 wk reclassification (ACOG 190; ADA 2025)
    advance: Level of care assigned
  11. 11MONITORING
    A1: SMBG 4×/day (fasting + 1-h or 2-h postprandial × 3 meals); fetal kick counts daily; NST/BPP weekly from 32 wk; growth scan q4 wk per ACOG 190. A2: same + insulin titration to targets (fasting < 95, 1-h PP < 140, 2-h PP < 120 per ACOG 190 + ADA 2025); CGM in pregnancy emerging — CONCEPTT 2017 PMID 28923465 (T1DM evidence base; off-label use in GDM)
    inputs: smbg_log, fetal_growth_us, nst_or_bpp, a1c
    actions: panel.glucose_a1c
    advance: Targets being met OR escalation to A2 OR delivery indicated
  12. 12FOLLOWUP
    Postpartum 75-g 2-h OGTT at 6-12 wk to reclassify (normal / IGT / DM per ADA 2025); lifetime DM2 risk 50-70% (Bellamy meta-analysis Lancet 2009 PMID 19465232; HR 7.43 for DM2 within 5 years); annual screening with HbA1c or fasting glucose per ADA 2025; DPP-derived lifestyle intervention (7% weight loss + 150 min/wk exercise reduces DM2 incidence by 58% per Knowler NEJM 2002 PMID 11832527); metformin consideration for IGT per ADA 2025; aspirin counseling for next pregnancy if PE history (USPSTF 2021 PMID 34581729)
    advance: Postpartum reclassification complete + lifelong screening plan documented