ob.gdm.core.v1PRODUCTION

ob.gdm.core.v1

Gestational Diabetes Mellitus (A1 / A2 — OB perspective)

obstetricssubacutechronicadultpregnancy

Hard-required inputs

0 / 9

Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

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

Actions

Advance rule

Set

Advance when

Screening eligibility assigned + overt-DM differential considered

Patient inputs (19)

pre_pregnancy_bmi*demographic • CONTEXT

BMI ≥ 30 = high-risk indication for early screening (ACOG 190)

prior_gdm*history • CONTEXT

not present

Recurrence ~ 60% (Kim Diabetes Care 2007 PMID 17290037) → early screen + counseling

prior_macrosomia*history • CONTEXT

not present

Prior infant > 4000 g = high-risk indication for early GDM screen (ACOG 190)

gestational_age*demographic • 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)

a1c*lab • INITIAL_WORKUP

A1c ≥ 6.5% first trimester → overt DM in pregnancy; trajectory < 6.0% optimal during pregnancy per ADA 2025

fasting_glucose*lab • INITIAL_WORKUP

Fasting glucose ≥ 126 first trimester = overt DM; SMBG fasting < 95 mg/dL target during pregnancy (ACOG 190)

smbg_log*lab • MONITORING

SMBG 4×/day (fasting + 1-h or 2-h postprandial × 3 meals) → drives A1 vs A2 classification (ACOG 190)

fetal_growth_us*imaging • MONITORING

not present

Growth scan q4 wk to detect macrosomia (EFW ≥ 95th %ile) or polyhydramnios (AFI > 24) → drives delivery timing (ACOG 190)

sbp*vital • RED_FLAGS

BP ≥ 140/90 raises superimposed pre-eclampsia concern; GDM increases PE risk 4-5× (HAPO-FUS)

pcoshistory • CONTEXT

not present

Polycystic ovary syndrome = high-risk indication; insulin resistance substrate (ACOG 190)

family_history_dm2history • CONTEXT

not present

First-degree relative with DM2 = high-risk indication (ACOG 190)

ethnic_high_riskhistory • CONTEXT

not present

Hispanic / Asian / Native American / African American baseline GDM prevalence ~ 10-15% vs general ~ 6-10% (USPSTF 2021)

current_insulin_or_ohamedication • CONTEXT

not present

Current insulin regimen / metformin / glyburide status — drives A1 vs A2 classification and titration plan

gct_50glab • 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_iadpsglab • 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_3hlab • 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

nst_or_bppimaging • MONITORING

not present

Weekly NST or BPP from 32 wk for A2 GDM; A1 well-controlled may defer per ACOG 190

decreased_fetal_movementsymptom • RED_FLAGS

Decreased kick counts → urgent NST/BPP + consider delivery (ACOG 190)

recurrent_hypoglycemiasymptom • RED_FLAGS

Recurrent hypoglycemia on insulin → adjust regimen + nutritional reassessment + CGM consideration (ADA 2025)

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

Severity triggers (7)

7 need judgement

informationallife_threateningdka_in_pregnancy_with_gdm
DKA in pregnancy with GDM — anion gap > 12 + ketonemia (serum ketones positive) + glucose ≥ 200 mg/dL + symptoms (nausea, vomiting, abdominal pain) (Sibai 2014 PMID 24463678: DKA in pregnancy can occur at lower glucose 200-250 mg/dL vs > 300 non-pregnant); maternal mortality 0-15%, fetal mortality 9-35%
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereearly_detected_first_trimester_gdm
GDM detected in first trimester via early screen (BMI ≥ 30, prior GDM, prior macrosomia, PCOS, ethnic risk, family DM2) → likely pre-existing T2DM unmasked; A1c ≥ 6.5% at conception → major-malformation risk 6-12% (Kitzmiller diabetes-in-pregnancy review)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverea2_gdm_glucose_uncontrolled_despite_insulin
A2 GDM with ≥ 50% glucose values exceeding target at multiple time-of-day points despite maximal insulin titration (basal + bolus per pattern) for 2-3 weeks → intensify insulin + endocrinology consult + MFM coordination + consider CGM (CONCEPTT 2017 PMID 28923465 evidence base in T1DM; off-label use in GDM)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveregdm_with_macrosomia_or_polyhydramnios
GDM with estimated fetal weight (EFW) ≥ 95th percentile (macrosomia ≥ 4000 g) OR amniotic fluid index (AFI) > 24 (polyhydramnios) → tighten glucose control + delivery timing reassessment + shoulder dystocia counseling; cesarean for EFW ≥ 4500 g per ACOG 190 (vs ≥ 5000 g in non-DM)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveregdm_with_recurrent_hypoglycemia
A2 GDM patient on insulin with recurrent hypoglycemia (≥ 2 episodes of BG < 70 mg/dL per week, or ≥ 1 severe episode requiring assistance/dextrose) → adjust insulin regimen + nutritional reassessment + CGM consideration; rule out renal dysfunction, hyperemesis-with-poor-intake, exercise-induced hypoglycemia
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveregdm_with_superimposed_pre_eclampsia
GDM patient develops new HTN ≥ 140/90 with proteinuria OR any severe-feature symptom (severe headache, visual changes, RUQ pain, plt < 100K, AST/ALT ≥ 2× ULN, Cr ≥ 1.1, pulmonary edema) after 20 wk → reclassify as superimposed pre-eclampsia + carryover handoff to ob.pre-eclampsia.core.v1 (overlap 4-5× per HAPO-FUS)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmildpostpartum_glucose_intolerance
Postpartum 75-g 2-h OGTT at 6-12 wk shows impaired glucose tolerance (fasting 100-125 OR 2-h 140-199 mg/dL per ADA 2025) OR overt diabetes (fasting ≥ 126 OR 2-h ≥ 200 OR A1c ≥ 6.5%) → route to endo.dm2.core.v1 for ongoing management + lifestyle + annual screening + metformin consideration per ADA 2025
Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONoptionalDrives dose adjustment

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Recommended regimen

GDM stepwise (OB perspective) — MNT first (A1) → insulin first-line (A2) → metformin/glyburide alternatives; SGLT2i / GLP-1 / DPP-4 contraindicated in pregnancy

axis: gdm_a1_a2_stepwise_ob_perspectivestep 1 - Step 1 — A1 GDM: Medical nutrition therapy + exercise + SMBG (ACOG 190 2018)

Selected step "Step 1 — A1 GDM: Medical nutrition therapy + exercise + SMBG (ACOG 190 2018)" — Newly diagnosed GDM, targets achievable with lifestyle alone (ACOG 190 2018)

outpatient playbook — drug actions (6)

1. MNT (RDN consult)
Carbohydrate distribution: 35-45% carb / ~25% protein / 35-40% fat across 3 meals + 2-3 snacks; avoid simple sugars • lifestyle • continuous
trigger: A1 GDM diagnosis
ACOG 190 (2018) first-line; ADA 2025 §15
2. physical activity
30 min/day moderate-intensity (e.g., brisk walk after meals) • lifestyle • daily
trigger: All GDM diagnoses
ACOG 190 (2018); ADA 2025 §15 — improves insulin sensitivity + postprandial glucose excursions
3. insulin NPH or detemir basal + lispro/aspart bolus
NPH 0.2 U/kg HS or 0.1 U/kg AM + 0.1 U/kg HS; lispro/aspart 4 U with meals causing 1-h elevation • SC • basal + meals
trigger: A2 GDM (≥ 50% values exceeding target at same time-of-day for 1-2 weeks despite MNT)
ACOG 190 + ADA 2025 §15 — first-line in A2; does not cross placenta
4. metformin (alternative)
500 mg BID titrate to 1000 mg BID over 2 weeks; max 2500 mg/day • PO • BID with meals
trigger: Insulin declined or access barrier
ACOG 190 (2018) accepts as alternative; ~ 46% require insulin add-on per MIG (Rowan NEJM 2008); crosses placenta but LactMed-compatible
5. aspirin 81 mg
81 mg PO daily from 12 wk through 36 wk • PO • daily
trigger: PE risk factors (≥ 1 high-risk OR ≥ 2 moderate-risk per USPSTF 2021)
USPSTF 2021 (PMID 34581729) + ACOG — GDM is moderate-risk PE factor; aspirin if any additional risk factor
6. antenatal corticosteroids (betamethasone)
12 mg IM q24h × 2 doses; INCREASE insulin TDD 30-50% × 5 days post-steroid • IM • one course
trigger: Threatened preterm delivery 24-34 wk
ACOG 190 — fetal lung maturation; pre-emptive insulin titration prevents steroid-induced hyperglycemia / DKA risk

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Pregnancy at 24-28 weeks → universal GDM screening (USPSTF 2021, PMID 34374716; ACOG 190); Early pregnancy + high-risk profile (BMI ≥ 30, prior GDM, prior macrosomia, PCOS, ethnic risk, family DM2) → early GDM screen (ACOG 190); 50-g GCT ≥ 140 mg/dL → proceed to 100-g 3-h OGTT (Carpenter-Coustan or NDDG) (ACOG 190).

Objective

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

Assessment

**Gestational Diabetes Mellitus (A1 / A2 — OB perspective)** (ob.gdm.core.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **GDM stepwise (OB perspective) — MNT first (A1) → insulin first-line (A2) → metformin/glyburide alternatives; SGLT2i / GLP-1 / DPP-4 contraindicated in pregnancy** — step "Step 1 — A1 GDM: Medical nutrition therapy + exercise + SMBG (ACOG 190 2018)".

Setting playbook (outpatient) — Diagnose GDM at universal 24-28 wk screen (USPSTF 2021 PMID 34374716) or earlier high-risk; classify A1 vs A2 via SMBG trends; achieve glucose targets with MNT (A1) ± insulin (A2) per ACOG 190 + ADA 2025; weekly fetal surveillance from 32 wk; deliver per phenotype-specific timing per delivery-timing consensus (Spong, Obstet Gynecol 2011, PMID 21775849); postpartum reclassification at 6-12 wk; lifelong DM screening (Bellamy Lancet 2009 PMID 19465232: 7-fold DM2 risk)
1. MNT (RDN consult) Carbohydrate distribution: 35-45% carb / ~25% protein / 35-40% fat across 3 meals + 2-3 snacks; avoid simple sugars lifestyle continuous — A1 GDM diagnosis (ACOG 190 (2018) first-line; ADA 2025 §15)
2. physical activity 30 min/day moderate-intensity (e.g., brisk walk after meals) lifestyle daily — All GDM diagnoses (ACOG 190 (2018); ADA 2025 §15 — improves insulin sensitivity + postprandial glucose excursions)
3. insulin NPH or detemir basal + lispro/aspart bolus NPH 0.2 U/kg HS or 0.1 U/kg AM + 0.1 U/kg HS; lispro/aspart 4 U with meals causing 1-h elevation SC basal + meals — A2 GDM (≥ 50% values exceeding target at same time-of-day for 1-2 weeks despite MNT) (ACOG 190 + ADA 2025 §15 — first-line in A2; does not cross placenta)
4. metformin (alternative) 500 mg BID titrate to 1000 mg BID over 2 weeks; max 2500 mg/day PO BID with meals — Insulin declined or access barrier (ACOG 190 (2018) accepts as alternative; ~ 46% require insulin add-on per MIG (Rowan NEJM 2008); crosses placenta but LactMed-compatible)
5. aspirin 81 mg 81 mg PO daily from 12 wk through 36 wk PO daily — PE risk factors (≥ 1 high-risk OR ≥ 2 moderate-risk per USPSTF 2021) (USPSTF 2021 (PMID 34581729) + ACOG — GDM is moderate-risk PE factor; aspirin if any additional risk factor)
6. antenatal corticosteroids (betamethasone) 12 mg IM q24h × 2 doses; INCREASE insulin TDD 30-50% × 5 days post-steroid IM one course — Threatened preterm delivery 24-34 wk (ACOG 190 — fetal lung maturation; pre-emptive insulin titration prevents steroid-induced hyperglycemia / DKA risk)

Non-pharmacologic actions:
- RDN-led MNT counselling at GDM diagnosis (ACOG 190 2018)
- Physical activity 30 min/day moderate (walk after meals) (ADA 2025 §15)
- Weight gain target per IOM (singleton normal BMI 18.5-24.9: 25-35 lb; overweight 25-29.9: 15-25 lb; obese ≥ 30: 11-20 lb) (ACOG 190 2018)
- CGM if available + insurance covers — emerging in GDM; CONCEPTT 2017 (PMID 28923465) is T1DM evidence base (ADA 2025 §15)
- OB + MFM coordination for A2 GDM or A1 with growth concerns (ACOG 190 2018)
- Endocrinology consult for A2 uncontrolled despite insulin or CGM needs (ADA 2025 §15)
- Delivery planning per phenotype (delivery-timing consensus (Spong, Obstet Gynecol 2011, PMID 21775849)): A1 well-controlled 39-40+6 wk; A2 well-controlled 39-39+6 wk; A2 poorly controlled or vasculopathy or EFW ≥ 95th %ile 37-38+6 wk; cesarean for EFW ≥ 4500 g per ACOG
- Postpartum 75-g 2-h OGTT scheduled at 6-12 wk; route to endo.dm2.core.v1 if DM; intensive lifestyle (DPP-derived 7% weight loss + 150 min/wk exercise) + metformin per ADA 2025 if IGT; annual screening lifelong (Bellamy Lancet 2009 PMID 19465232)
- Aspirin counseling for next pregnancy: 81 mg PO daily from 12 wk per USPSTF 2021 PMID 34581729 if any PE history
- Breastfeeding encouragement — reduces future maternal DM2 risk (ADA 2025 §15)

AVOID / contraindication checks:
- Never SGLT2i in pregnancy (ADA 2025 §15) — insufficient pregnancy safety data
- Never GLP 1 receptor agonist in pregnancy (ADA 2025 §15) — insufficient pregnancy safety data
- Never DPP 4 inhibitor in pregnancy (ADA 2025 §15) — limited pregnancy safety data
- Never TZD in pregnancy (ADA 2025 §15)
- Glyburide not recommended per ACOG 190 (2018) + superseded by insulin per ADA 2025
- Metformin alone inadequate in severe GDM (Rowan NEJM 2008 MIG — ~ 46% require insulin add on)
- ACE/ARB/renin inhibitor teratogenic — use methyldopa or labetalol for HTN in pregnancy (ACOG 190)
- Insulin does not cross placenta — first line in GDM per ACOG 190 + ADA 2025
- Metformin crosses placenta — LactMed compatible postpartum but long term offspring data evolving (MIG 2 yr follow up: slightly higher subcutaneous fat)

Monitoring

Regimen monitoring:
- SMBG QID — fasting + 1-h OR 2-h postprandial × 3 meals (ACOG 190 2018)
- Fasting target < 95 mg/dL (ACOG 190 2018; ADA 2025 §15)
- 1-h postprandial target < 140 mg/dL (ACOG 190 2018; ADA 2025 §15)
- 2-h postprandial target < 120 mg/dL (ACOG 190 2018; ADA 2025 §15)
- A1c q trimester (target < 6.0% optimal per ADA 2025 §15)
- Weekly OB review third trimester (ACOG 190 2018)
- Growth US q4 weeks third trimester (ACOG 190 2018)
- NST/BPP weekly from 32 wk for A2; per OB protocol for A1 (ACOG 190 2018)
- Fetal kick counts daily from 28 wk (ACOG 190 2018)
- BP at every visit (PE overlap; GDM increases PE risk 4-5x per HAPO-FUS)
- CGM available + insurance covers — emerging in GDM; CONCEPTT 2017 (PMID 28923465) is T1DM evidence base (ADA 2025 §15)
- Postpartum 75-g 2-h OGTT at 6-12 wk postpartum (ACOG 190 2018; ADA 2025 §15)
- Annual DM screening lifelong with HbA1c or fasting glucose (ADA 2025 §15; Bellamy Lancet 2009 PMID 19465232: 7-fold DM2 risk)

Setting (outpatient) monitoring:
- SMBG QID (fasting + 1-h or 2-h postprandial × 3 meals) (ACOG 190 2018)
- Targets: fasting < 95 mg/dL, 1-h PP < 140 mg/dL, 2-h PP < 120 mg/dL (ACOG 190 2018; ADA 2025 §15)
- A1c q trimester (target < 6.0% per ADA 2025 §15)
- Weekly OB review third trimester (ACOG 190 2018)
- Growth US q4w third trimester (ACOG 190 2018)
- NST/BPP weekly from 32 wk for A2 GDM (ACOG 190 2018)
- Fetal kick counts daily from 28 wk (ACOG 190 2018)
- BP at every visit + UPCR if BP ≥ 140/90 (PE overlap)
- Postpartum SMBG q4h × 24-48 h then stop unless overt DM in pregnancy (ADA 2025 §15)
- 75-g 2-h OGTT at 6-12 wk postpartum to reclassify (ADA 2025 §15)
- Lifelong annual DM screening (HbA1c or fasting glucose) per ADA 2025 §15

Follow-up plan: 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)
- Close-out criterion: Postpartum reclassification complete + lifelong screening plan documented

Monitoring phase: 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)

Disposition

Current setting: outpatient — Diagnose GDM at universal 24-28 wk screen (USPSTF 2021 PMID 34374716) or earlier high-risk; classify A1 vs A2 via SMBG trends; achieve glucose targets with MNT (A1) ± insulin (A2) per ACOG 190 + ADA 2025; weekly fetal surveillance from 32 wk; deliver per phenotype-specific timing per delivery-timing consensus (Spong, Obstet Gynecol 2011, PMID 21775849); postpartum reclassification at 6-12 wk; lifelong DM screening (Bellamy Lancet 2009 PMID 19465232: 7-fold DM2 risk)

Disposition criteria:
- Continue outpatient if targets met + reassuring fetal status (ACOG 190 2018)
- Antenatal admission for poor control + remote-from-term OR severe macrosomia (ACOG 190 2018)
- L&D for phenotype-timing delivery per SMFM 2017 (A1: 39-40+6; A2 well-controlled: 39-39+6; A2 poorly controlled: 37-38+6)
- Postpartum: discharge once 75-g OGTT scheduled at 6-12 wk + lifestyle counseling + PCP + OB follow-up + contraception counseled (ADA 2025 §15; ACOG 190 2018)

Escalation triggers (move to higher acuity):
- Persistent hyperglycemia despite MNT 1-2 wk (≥ 50% values exceeding target at same time-of-day) → escalate to A2 insulin (ACOG 190 2018)
- EFW ≥ 95th %ile or 4000 g → growth-scan acceleration + delivery-timing reassessment + cesarean discussion if ≥ 4500 g per ACOG
- Polyhydramnios AFI > 24 → re-screen glucose control + MFM consult + rule out fetal anomalies (ACOG 190 2018)
- New BP ≥ 140/90 or proteinuria → PE engine + ED if severe HTN (ACOG 190 2018; route to ob.pre-eclampsia.core.v1)
- Recurrent hypoglycemia on insulin (BG < 70 multiple times) → adjust insulin regimen + nutritional reassessment + CGM consideration (ADA 2025 §15)
- A1c ≥ 6.5% at first trimester → reclassify as overt DM in pregnancy + insulin + major-malformation US at 18-20 wk + MFM
- Decreased fetal movement OR abnormal NST → L&D evaluation (ACOG 190 2018)
- Hyperglycemia symptoms + ketonuria + nausea/vomiting → ED for DKA-in-pregnancy workup (Sibai 2014 PMID 24463678; route to endo.dka.core.v1)
- Postpartum 75-g OGTT showing DM at 6-12 wk → route to endo.dm2.core.v1 for ongoing management (ADA 2025 §15)

Patient Action Plan

**Gestational diabetes mellitus home action plan — ACOG 190 (2018, reaff 2024) + ADA 2025 §15**
Personalised values: gestational_age, current_insulin_or_oha, glucose_targets, OB_provider_contact.

**On target — SMBG within range, no symptoms, normal kick counts** (green):
Triggers:
- Fasting < 95 mg/dL (ACOG 190 + ADA 2025)
- 1-h postprandial < 140 mg/dL OR 2-h PP < 120 mg/dL (ACOG 190 + ADA 2025)
- Normal fetal kick counts (≥ 10 in 2 h) (ACOG 190)
- No symptoms of hypoglycemia OR hyperglycemia
Actions:
- Continue MNT (35-45% carb, 3 meals + 2-3 snacks) (ACOG 190)
- Continue insulin or metformin as prescribed (ACOG 190; ADA 2025 §15)
- Continue 30 min/day moderate exercise (ADA 2025 §15)
- Continue aspirin 81 mg daily through 36 weeks if started (USPSTF 2021)
- SMBG QID + log values (ACOG 190)
- Daily kick counts from 28 wk (ACOG 190)
- Attend all scheduled prenatal visits + NSTs + growth scans (ACOG 190)

**Caution — Out of range, mild symptoms, or new concern** (yellow):
Triggers:
- Fasting 95-125 OR 1-h PP 140-180 OR 2-h PP 120-160 mg/dL repeatedly (ACOG 190)
- Mild hypoglycemia (BG 55-69) responding to 15 g carb rule (ACOG 190)
- Reduced (but not absent) fetal movement (ACOG 190)
- Mild swelling or weight gain accelerating > 1 lb/wk (ACOG 190)
- Single severe-range hyperglycemic reading without symptoms
Actions:
- Recheck SMBG before next meal (ACOG 190)
- Review carb intake at meal causing elevation (ACOG 190)
- If hypoglycemic, 15 g fast-acting carb + recheck in 15 min (ACOG 190)
- Drink water + lie left-side if reduced fetal movement (ACOG 190)
- Daily kick count focused 1-h count (ACOG 190)
- Call OB or GDM clinic same business day (ACOG 190)
- Continue insulin/metformin + MNT as prescribed (ACOG 190)
Contact provider when:
- SMBG values out of range > 2 consecutive readings at same time-of-day (ACOG 190)
- Persistent reduced fetal movement (ACOG 190)
- Accelerating weight gain > 1 lb/wk over baseline (ACOG 190)
- Mild hypoglycemia twice in same day (ACOG 190)

**Medical alert — go to L&D / ED now** (red):
Triggers:
- Severe hyperglycemia BG > 250 mg/dL with ketones in urine or symptoms (nausea, vomiting, abdominal pain) (Sibai 2014 PMID 24463678 — DKA-in-pregnancy thresholds lower)
- Severe hypoglycemia BG < 55 mg/dL with neuroglycopenia (confusion, seizure, LOC)
- Severe headache not relieved by acetaminophen, visual changes, RUQ pain (PE severe features per ACOG 222)
- BP ≥ 160/110 on home cuff (single reading) or two readings ≥ 150/100 in 15 min (ACOG 767)
- Decreased fetal movement (< 10 kicks in 2 h after focused counting) (ACOG 190)
- Vaginal bleeding, leaking fluid, contractions (ACOG 190)
- Seizure or loss of consciousness (ACOG 190 + ACOG 222)
Actions:
- Go to L&D / ED immediately — do not wait (ACOG 190)
- Call 911 if seizing or unable to travel safely (ACOG 190)
- Bring insulin/metformin list, SMBG log, BP log (ACOG 190)
- If hypoglycemic + conscious: take 30 g carb + go to ED (ACOG 190)
- If hyperglycemic + symptoms: bring urine ketone strip result (Sibai 2014 PMID 24463678)
Contact provider when:
- Any red-zone trigger — proceed to L&D, do not call first (ACOG 190)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] DKA in pregnancy with GDM — anion gap > 12 + ketonemia (serum ketones positive) + glucose ≥ 200 mg/dL + symptoms (nausea, vomiting, abdominal pain) (Sibai 2014 PMID 24463678: DKA in pregnancy can occur at lower glucose 200-250 mg/dL vs > 300 non-pregnant); maternal mortality 0-15%, fetal mortality 9-35%
- [SEVERE] GDM detected in first trimester via early screen (BMI ≥ 30, prior GDM, prior macrosomia, PCOS, ethnic risk, family DM2) → likely pre-existing T2DM unmasked; A1c ≥ 6.5% at conception → major-malformation risk 6-12% (Kitzmiller diabetes-in-pregnancy review)
- [SEVERE] A2 GDM with ≥ 50% glucose values exceeding target at multiple time-of-day points despite maximal insulin titration (basal + bolus per pattern) for 2-3 weeks → intensify insulin + endocrinology consult + MFM coordination + consider CGM (CONCEPTT 2017 PMID 28923465 evidence base in T1DM; off-label use in GDM)

Citations

- ACOG Practice Bulletin 190 (Gestational Diabetes Mellitus, 2018, reaffirmed 2024) + ADA Standards of Care 2025 Chapter 15 (Management of Diabetes in Pregnancy) + USPSTF 2021 universal screening (Davidson JAMA 2021, PMID 34374716) + IADPSG 2010 consensus (PMID 20190296) + Spong 2011 delivery-timing consensus (Obstet Gynecol 2011, PMID 21775849) + HAPO 2008 (Metzger NEJM 2008, PMID 18463375) + MIG 2008 (Rowan NEJM 2008, PMID 18463376) + ACHOIS 2005 (Crowther NEJM 2005, PMID 15951574) + CONCEPTT 2017 (Feig Lancet 2017, PMID 28923465) + DPP 2002 (Knowler NEJM 2002, PMID 11832527) + Bellamy 2009 (Lancet 2009, PMID 19465232) + Kim 2007 (Diabetes Care 2007, PMID 17290037) + Sibai 2014 (Obstet Gynecol 2014, PMID 24463678) + USPSTF 2021 aspirin (Davidson JAMA 2021, PMID 34581729) [PMID:34374716](https://pubmed.ncbi.nlm.nih.gov/34374716/)
- Cited evidence (PMID 18463375) [PMID:18463375](https://pubmed.ncbi.nlm.nih.gov/18463375/)
- Cited evidence (PMID 18463376) [PMID:18463376](https://pubmed.ncbi.nlm.nih.gov/18463376/)
- Cited evidence (PMID 15951574) [PMID:15951574](https://pubmed.ncbi.nlm.nih.gov/15951574/)
- Cited evidence (PMID 28923465) [PMID:28923465](https://pubmed.ncbi.nlm.nih.gov/28923465/)

Last reconciled with current guidelines: 2026-05-25.

References

ACOG Practice Bulletin 190 (Gestational Diabetes Mellitus, 2018, reaffirmed 2024) + ADA Standards of Care 2025 Chapter 15 (Management of Diabetes in Pregnancy) + USPSTF 2021 universal screening (Davidson JAMA 2021, PMID 34374716) + IADPSG 2010 consensus (PMID 20190296) + Spong 2011 delivery-timing consensus (Obstet Gynecol 2011, PMID 21775849) + HAPO 2008 (Metzger NEJM 2008, PMID 18463375) + MIG 2008 (Rowan NEJM 2008, PMID 18463376) + ACHOIS 2005 (Crowther NEJM 2005, PMID 15951574) + CONCEPTT 2017 (Feig Lancet 2017, PMID 28923465) + DPP 2002 (Knowler NEJM 2002, PMID 11832527) + Bellamy 2009 (Lancet 2009, PMID 19465232) + Kim 2007 (Diabetes Care 2007, PMID 17290037) + Sibai 2014 (Obstet Gynecol 2014, PMID 24463678) + USPSTF 2021 aspirin (Davidson JAMA 2021, PMID 34581729) — PMID:34374716
Cited evidence (PMID 18463375) — PMID:18463375
Cited evidence (PMID 18463376) — PMID:18463376
Cited evidence (PMID 15951574) — PMID:15951574
Cited evidence (PMID 28923465) — PMID:28923465