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endo.gestational-diabetes.chronic.v1PRODUCTION
endo.gestational-diabetes.chronic.v1

Gestational diabetes (GDM)

obstetricschronicpregnancyadult
Hard-required inputs
0 / 6
Care setting:

Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Distinguish GDM (new in pregnancy) from overt pre-existing DM (A1c ≥6.5% in early pregnancy → manage as pregestational DM) (ADA 2026 §15)

Inputs
2
Actions
0
Advance rule
Set
Advance when

GDM vs overt DM classification made

Patient inputs (9)

Screening (24-28 wk), delivery timing, fetal monitoring intensity (ACOG 190 2018)

Risk stratification; advanced maternal age modifier (ADA 2026 §15)

Pre-pregnancy BMI gates risk + weight-gain target (ACOG 190 2018)

~50% recurrence; earlier screen at 6-12 wk (ADA 2026 §15)

Diagnostic threshold (one-step ≥92, two-step varies) (IADPSG; Metzger NEJM 2008)

75g IADPSG one-step or 100g Carpenter-Coustan two-step (ACOG 190 2018; ADA 2026 §15)

Pre-pregnancy insulin resistance increases GDM risk (ADA 2026 §15)

First-degree relative T2DM raises baseline risk (ADA 2026 §15)

Distinguishes overt pre-existing DM from GDM in early pregnancy (ADA 2026 §15)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationalseverepreeclampsia_overlap
    New BP ≥140/90 OR proteinuria OR severe-features symptoms (ACOG 190 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereovert_DM_in_pregnancy
    A1c ≥6.5% OR FPG ≥126 in early pregnancy (ADA 2026 §15)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremacrosomia_consider_csection
    EFW ≥4500 g in GDM (ACOG 190 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemnt_failure_start_insulin
    Fasting >95 OR postprandial out of target on ≥2 occasions/week despite 1–2 wk MNT (ACOG 190 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateestimated_fetal_weight_gt_90th
    EFW >90th percentile + persistent maternal hyperglycemia (ACOG 190 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateantenatal_steroid_hyperglycemia
    Betamethasone for fetal lung maturation in known GDM (ACOG 190 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepostpartum_OGTT_overdue
    No 75g OGTT done 4–12 weeks postpartum (ADA 2026 §15)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

GDM stepwise — MNT first → insulin (preferred) → metformin (alternative); SGLT2i/GLP-1 contraindicated
axis: gdm_pregnancy_safe_stepwisestep 1 - Step 1 — Medical nutrition therapy (MNT) + monitoring (ACOG 190 2018)
Selected step "Step 1 — Medical nutrition therapy (MNT) + monitoring (ACOG 190 2018)" — Newly diagnosed GDM (A1 class) (ACOG 190 2018)

outpatient playbook — drug actions (5)

  1. 1. MNT (RDN consult)
    Carbohydrate distribution: ~40% carb / ~25% protein / ~35% fat across 3 meals + 2–3 snacks • lifestyle • continuous
    trigger: Diagnosis
    ACOG 190 (2018) first-line; ADA 2026 §15
  2. 2. insulin NPH or detemir + lispro/aspart
    NPH 0.2 U/kg HS or 0.1 U/kg AM + 0.1 U/kg HS; lispro 4 U with meals • SC • basal + meals
    trigger: 1–2 weeks MNT failure or excess fetal growth
    Pregnancy preferred (ACOG 190 2018; ADA 2026 §15)
  3. 3. metformin (alternative)
    500 mg BID titrate to 1000 mg BID • PO • BID
    trigger: Insulin declined or access barrier
    ACOG 190 (2018) accepts but ~46% need insulin add (Rowan NEJM 2008 MIG)
  4. 4. aspirin 81 mg
    81 mg PO daily from 12–28 wk • PO • daily
    trigger: PE risk factors (chronic HTN, prior PE, T1/T2DM, multifetal, BMI ≥35, age ≥35)
    USPSTF 2021 + ACOG PE prevention
  5. 5. antenatal corticosteroids (betamethasone)
    12 mg IM q24h × 2 doses • IM • one course
    trigger: Threatened preterm delivery 24–34 wk; INCREASE insulin 30–50% for 5 days post-steroid
    ACOG 190 (2018) — fetal lung maturation; steroid hyperglycemia significant in GDM

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Positive 50g GCT or 75g/100g OGTT (24-28 wk) (ACOG 190 2018; ADA 2026 §15); Routine 24-28 wk universal screening (ACOG 190 2018; ADA 2026 §15); Early-pregnancy A1c ≥6.5% / FPG ≥126 (overt DM in pregnancy) (ADA 2026 §15).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Gestational diabetes (GDM)** (endo.gestational-diabetes.chronic.v1).
Phenotype framing: GDM A1 (diet-controlled) vs A2 (medication-requiring); rule out unmasked T2DM (A1c, FPG) (ACOG 190 2018; ADA 2026 §15)
Scope: Distinguish GDM (new in pregnancy) from overt pre-existing DM (A1c ≥6.5% in early pregnancy → manage as pregestational DM) (ADA 2026 §15)

No severity triggers fired against current inputs.

Plan

Regimen axis: **GDM stepwise — MNT first → insulin (preferred) → metformin (alternative); SGLT2i/GLP-1 contraindicated** — step "Step 1 — Medical nutrition therapy (MNT) + monitoring (ACOG 190 2018)".

Setting playbook (outpatient) — Maintain glycemic targets with MNT ± insulin to reduce macrosomia, shoulder dystocia, neonatal hypoglycemia, preeclampsia, and lifelong T2DM risk (ACOG 190 2018; ADA 2026 §15)
1. MNT (RDN consult) Carbohydrate distribution: ~40% carb / ~25% protein / ~35% fat across 3 meals + 2–3 snacks lifestyle continuous — Diagnosis (ACOG 190 (2018) first-line; ADA 2026 §15)
2. insulin NPH or detemir + lispro/aspart NPH 0.2 U/kg HS or 0.1 U/kg AM + 0.1 U/kg HS; lispro 4 U with meals SC basal + meals — 1–2 weeks MNT failure or excess fetal growth (Pregnancy preferred (ACOG 190 2018; ADA 2026 §15))
3. metformin (alternative) 500 mg BID titrate to 1000 mg BID PO BID — Insulin declined or access barrier (ACOG 190 (2018) accepts but ~46% need insulin add (Rowan NEJM 2008 MIG))
4. aspirin 81 mg 81 mg PO daily from 12–28 wk PO daily — PE risk factors (chronic HTN, prior PE, T1/T2DM, multifetal, BMI ≥35, age ≥35) (USPSTF 2021 + ACOG PE prevention)
5. antenatal corticosteroids (betamethasone) 12 mg IM q24h × 2 doses IM one course — Threatened preterm delivery 24–34 wk; INCREASE insulin 30–50% for 5 days post-steroid (ACOG 190 (2018) — fetal lung maturation; steroid hyperglycemia significant in GDM)

Non-pharmacologic actions:
- RDN-led MNT counselling (ACOG 190 2018)
- Physical activity 30 min/day moderate (walk after meals) (ADA 2026 §15)
- Weight gain target per IOM (singleton normal BMI: 25–35 lb; obese: 11–20 lb) (ACOG 190 2018)
- CGM if available + insurance covers (ADA 2026 §15)
- OB + MFM coordination (ACOG 190 2018)
- Delivery planning: 39–40 wk if well-controlled MNT-only, 39 wk if A2 well-controlled, earlier if poor control or macrosomia (>4500 g consider C/S) (ACOG 190 2018)
- Postpartum: stop GDM-specific insulin; 75g OGTT at 4–12 wk postpartum (ADA 2026 §15; ACOG 190 2018)

AVOID / contraindication checks:
- Never SGLT2i in pregnancy (ADA 2026 §15)
- Never GLP1 RA in pregnancy (ADA 2026 §15)
- Never DPP4 in pregnancy (ADA 2026 §15)
- Never TZD in pregnancy (ADA 2026 §15)
- Glyburide not recommended per ACOG 190 (2018)
- Metformin alone inadequate in severe GDM (Rowan NEJM 2008 MIG)
- ACE/ARB teratogenic — switch to methyldopa or labetalol for HTN (ACOG 190 2018)

Monitoring

Regimen monitoring:
- SMBG QID fasting and 1h postprandial (ACOG 190 2018)
- Fasting target <95 (ADA 2026 §15)
- 1h postprandial target <140 (ADA 2026 §15)
- 2h postprandial target <120 (ADA 2026 §15)
- Weekly OB review third trimester (ACOG 190 2018)
- Growth US q4 weeks third trimester (ACOG 190 2018)
- NST/BPP per OB protocol (ACOG 190 2018)
- Fetal kick counts daily 28w onwards (ACOG 190 2018)
- A1c q trimester (ADA 2026 §15)

Setting (outpatient) monitoring:
- SMBG QID (fasting + 1h post-prandial) (ACOG 190 2018)
- Targets: FPG <95, 1h <140, 2h <120 (ADA 2026 §15)
- Weekly OB review third trimester (ACOG 190 2018)
- Growth US q4w third trimester (ACOG 190 2018)
- NST/BPP per protocol (ACOG 190 2018)
- Fetal kick counts daily (ACOG 190 2018)
- BP at each visit (ACOG 190 2018)
- UACR + LFT if PE concern (ADA 2026 §15)

Follow-up plan: 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)
- Close-out criterion: postpartum OGTT scheduled; lifelong follow-up plan made

Monitoring phase: 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)

Disposition

Current setting: outpatient — Maintain glycemic targets with MNT ± insulin to reduce macrosomia, shoulder dystocia, neonatal hypoglycemia, preeclampsia, and lifelong T2DM risk (ACOG 190 2018; ADA 2026 §15)

Disposition criteria:
- Continue outpatient if targets met + reassuring fetal status (ACOG 190 2018)
- Inpatient admission for poor control + 32+ weeks if remote OR severe macrosomia (ACOG 190 2018)
- L&D for term delivery per phenotype timing (ACOG 190 2018)

Escalation triggers (move to higher acuity):
- Persistent hyperglycemia despite MNT 1–2 wk → start insulin (ACOG 190 2018)
- Estimated fetal weight >90th percentile → consider insulin even with normal SMBG (ACOG 190 2018; Crowther Lancet 2005 ACHOIS)
- New BP ≥140/90 or proteinuria → preeclampsia engine + ED if severe (ACOG 190 2018)
- Polyhydramnios → MFM (ACOG 190 2018)
- Decreased fetal movement / abnormal NST → L&D evaluation (ACOG 190 2018)

Patient Action Plan

**GDM glucose action plan — fasting + post-prandial zones**
Personalised values: gestational_age, GDM_class_A1_or_A2, insulin_regimen, fetal_growth_status.

**On track — targets met** (green):
Triggers:
- Fasting BG 70–95 mg/dL (ADA 2026 §15)
- 1h postprandial <140 mg/dL (ADA 2026 §15)
- 2h postprandial <120 mg/dL (ADA 2026 §15)
- No symptoms (ACOG 190 2018)
- Normal fetal movements (ACOG 190 2018)
Actions:
- Continue MNT (carb distribution + portion control) (ACOG 190 2018)
- Continue insulin/metformin if prescribed (ACOG 190 2018)
- Daily kick counts after 28 wk (ACOG 190 2018)
- Weekly OB visits in third trimester (ACOG 190 2018)
- Bring SMBG log to every visit (ADA 2026 §15)

**Caution — out-of-target glucose** (yellow):
Triggers:
- Fasting BG >95 mg/dL on ≥2 days/week (ADA 2026 §15)
- 1h postprandial >140 mg/dL on ≥2 days/week (ADA 2026 §15)
- 2h postprandial >120 mg/dL on ≥2 days/week (ADA 2026 §15)
- New diet difficulties (ACOG 190 2018)
- Mild weight loss or excess gain (ACOG 190 2018; ADA 2026 §15)
Actions:
- Review carb distribution + portion sizes (ACOG 190 2018)
- Increase activity (10–15 min walk after meals) (ADA 2026 §15)
- Contact OB/diabetes team within 1 week if persistently out of target (ACOG 190 2018)
- Bring SMBG log to next visit; insulin start may be needed (ACOG 190 2018)
- Continue daily kick counts (ACOG 190 2018)
Contact provider when:
- Persistent fasting >95 or postprandial out of target ≥7 days (ADA 2026 §15)
- Difficulty following MNT (ACOG 190 2018)
- New symptoms (excessive thirst/urination) (ADA 2026 §15)

**Emergency — DKA, severe hypo, decreased fetal movement, severe HTN** (red):
Triggers:
- BG >300 mg/dL with vomiting / abdominal pain / Kussmaul (rare in GDM but possible) (ADA 2026 §15)
- BG <54 OR severe hypo requiring assistance (ADA 2026 §15)
- Decreased fetal movement (<10 movements/2h) (ACOG 190 2018)
- BP ≥160/110 OR severe headache, visual changes, RUQ pain (preeclampsia) (ACOG 190 2018)
- Vaginal bleeding / contractions / leaking fluid (ACOG 190 2018)
Actions:
- Severe hypo: take 15 g fast carb (juice, glucose tabs); recheck 15 min; have caregiver give glucagon if unable to swallow + call 911 (ADA 2026 §15)
- High BG with symptoms: call OB/911 + go to L&D (ACOG 190 2018)
- Decreased fetal movement: L&D now (ACOG 190 2018)
- Severe BP / headache / vision changes: L&D now (preeclampsia) (ACOG 190 2018)
- Bleeding / contractions: L&D now (ACOG 190 2018)
Contact provider when:
- Any red zone trigger — go to L&D, do not wait (ACOG 190 2018)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] New BP ≥140/90 OR proteinuria OR severe-features symptoms (ACOG 190 2018)
- [SEVERE] A1c ≥6.5% OR FPG ≥126 in early pregnancy (ADA 2026 §15)
- [SEVERE] EFW ≥4500 g in GDM (ACOG 190 2018)

Citations

- ACOG Practice Bulletin 190 (GDM, 2018, reaffirmed) + ADA Standards of Care 2026 Ch 15 (Management of Diabetes in Pregnancy) + IADPSG one-step 75g OGTT consensus + USPSTF 2021 (aspirin for PE prevention) + Carpenter-Coustan two-step thresholds. Canonical trials (PMIDs live-verified in pmids[]): ACHOIS (Crowther NEJM 2005), Landon MFMU NEJM 2009, HAPO Metzger NEJM 2008, MIG Rowan NEJM 2008. [PMID:29370047](https://pubmed.ncbi.nlm.nih.gov/29370047/)
- Cited evidence (PMID 39651985) [PMID:39651985](https://pubmed.ncbi.nlm.nih.gov/39651985/)
- Cited evidence (PMID 15951574) [PMID:15951574](https://pubmed.ncbi.nlm.nih.gov/15951574/)
- Cited evidence (PMID 19797280) [PMID:19797280](https://pubmed.ncbi.nlm.nih.gov/19797280/)
- Cited evidence (PMID 18463375) [PMID:18463375](https://pubmed.ncbi.nlm.nih.gov/18463375/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ACOG Practice Bulletin 190 (GDM, 2018, reaffirmed) + ADA Standards of Care 2026 Ch 15 (Management of Diabetes in Pregnancy) + IADPSG one-step 75g OGTT consensus + USPSTF 2021 (aspirin for PE prevention) + Carpenter-Coustan two-step thresholds. Canonical trials (PMIDs live-verified in pmids[]): ACHOIS (Crowther NEJM 2005), Landon MFMU NEJM 2009, HAPO Metzger NEJM 2008, MIG Rowan NEJM 2008. — PMID:29370047
  • Cited evidence (PMID 39651985) — PMID:39651985
  • Cited evidence (PMID 15951574) — PMID:15951574
  • Cited evidence (PMID 19797280) — PMID:19797280
  • Cited evidence (PMID 18463375) — PMID:18463375