Gestational diabetes mellitus (GDM) is one of the most common metabolic complications during pregnancy. Its prevalence has been increasing year by year, in parallel with rising maternal age and obesity rates. Previous studies have demonstrated that GDM is strongly associated with preeclampsia, macrosomia, shoulder dystocia, neonatal hypoglycemia, and long‑term metabolic risks in the mother. However, in clinical practice, substantial variations remain in GDM management strategies, with inconsistent intensity of monitoring and interventions.
Part 01 Background and Clinical Significance of the Guideline
In 2025, the World Health Organization (WHO) released the Recommendations on care for women with diabetes during pregnancy, hereinafter referred to as “the Recommendations”. For the first time, it systematically provides management recommendations covering gestational diabetes mellitus, as well as type 1 and type 2 diabetes in pregnancy. With the core goal of improving maternal and perinatal outcomes, the Recommendations emphasize individualized, evidence‑based care, while fully considering feasibility across settings with different levels of healthcare resources.
Based on the original text of the WHO 2025 Recommendations, this article provides a clinically oriented interpretation of the core management strategies for gestational diabetes mellitus, aiming to offer evidence‑based guidance for frontline obstetricians and gynecologists.
Part 02 General Principles of Management: Clear Classification and Outcome Orientation
The WHO Recommendations clearly state that gestational diabetes mellitus, type 2 diabetes in pregnancy, and type 1 diabetes in pregnancy differ significantly in pathophysiology, perinatal risks, and management priorities. Accurate classification is the primary prerequisite for clinical management.
In contrast to some clinical practices that treat GDM identically to pre‑gestational diabetes, the WHO does not support a uniform, high‑intensity monitoring and intervention strategy for all pregnant women with diabetes. The Recommendations emphasize that the core goal of diabetes management in pregnancy is to reduce the risk of adverse perinatal outcomes, rather than merely pursuing strict uniformity of glycemic targets. Therefore, glycemic control goals and follow‑up intensity should be dynamically adjusted according to diabetes type, treatment modality, and individual risk level.
Part 03 Non‑Pharmacological Management: The Foundation of GDM Care
01 Dietary Management
The WHO Recommendations recommend individualized dietary counseling for all pregnant women with diabetes, following general healthy eating principles rather than a specialized “glycemic control diet for pregnancy”. Specifically:
Prioritize whole grains, vegetables, fruits, and legumes as main carbohydrate sources;
Consume at least 400 g of vegetables per day;
Ensure dietary fiber intake of at least 25 g per day;
Limit free sugars to less than 5%–10% of total energy intake.
The Recommendations specifically advise against extremely low‑carbohydrate diets or prolonged food restriction due to fear of hyperglycemia, as these practices may lead to insufficient maternal nutrient intake and increase the risk of fetal growth restriction.
02 Physical Activity and Weight Management
The WHO Recommendations recommend that, in the absence of contraindications, pregnant women engage in at least 150 minutes of moderate‑intensity aerobic exercise per week, combined with moderate resistance training when feasible. For women with GDM, daily activity should not be restricted solely based on the diagnosis.
For weight management, the guideline stresses avoiding excessive weight gain, yet also discourages artificial suppression of gestational weight gain. The goal is to achieve appropriate gestational weight gain to reduce the risks of both macrosomia and low birth weight.
Part 04 Glycemic Monitoring Strategies: Rational Intensity Allocation
The WHO Recommendations recommend self‑monitoring of blood glucose (SMBG) for all pregnant women with diabetes where resources allow. However, the guideline does not mandate a universal monitoring frequency; instead, it recommends individualization based on diabetes type, pharmacotherapy use, and stability of glycemic control.
Regarding continuous glucose monitoring (CGM), the WHO Recommendations recommend its use in women with type 1 diabetes in pregnancy (where available), but do not recommend routine CGM in women with type 2 diabetes in pregnancy or GDM. Current evidence shows limited improvement in perinatal outcomes with CGM in the GDM population, and its use should balance resource availability and potential benefits.
Part 05 Pharmacological Therapy: Evidence-Based Positioning of Metformin in Pregnancy
When lifestyle interventions fail to achieve glycemic targets, the WHO recommends initiating pharmacotherapy. For GDM and type 2 diabetes in pregnancy, the WHO Recommendations clearly identify metformin or insulin as acceptable first‑line options; combination therapy may be considered if monotherapy is insufficient.
This recommendation establishes metformin as an evidence‑based, acceptable treatment in pregnancy, not merely a second‑line alternative when insulin is unavailable. Meanwhile, the WHO Recommendations strongly advise avoiding glucose‑lowering agents with insufficient safety data in pregnancy, such as sodium‑glucose cotransporter 2 (SGLT2) inhibitors and glucagon‑like peptide‑1 (GLP‑1) receptor agonists.
Part 06 Fetal and Maternal Surveillance: Risk-Based Individualization
The WHO Recommendations recommend that all pregnant women with diabetes undergo at least one detailed ultrasound examination before 24 weeks of gestation. The need for additional fetal growth monitoring or fetal surveillance should be comprehensively assessed based on diabetes type, glycemic control, pharmacotherapy, and coexisting maternal conditions; the guideline does not recommend a fixed schedule of routine ultrasounds.
For maternal complication screening, the WHO Recommendations recommend fundoscopy and renal function assessment in women with type 1 or type 2 diabetes in pregnancy, but do not recommend routine screening for uncomplicated GDM. Nonetheless, the guideline emphasizes room for individualized clinical judgment.
Part 07 Implications for Clinical Practice
The core philosophy of the 2025 WHO Recommendations is to maximize maternal and fetal benefits through evidence‑based, risk‑stratified management, while avoiding unnecessary medical interventions. For frontline obstetricians and gynecologists, the Recommendations highlight that GDM care should prioritize non‑pharmacological interventions, rationally select monitoring and treatment strategies, and avoid algorithmic escalation of care intensity solely based on diagnosis.
Conclusion
The 2025 WHO Recommendations provide a systematic, implementable, evidence‑based framework for the management of diabetes in pregnancy. Its emphasis on outcome‑driven, individualized care is highly relevant for standardizing clinical practice and optimizing healthcare resource allocation, warranting further dissemination and application across all levels of medical institutions.
Image source: WHO recommendations on care for women with diabetes during pregnancy
Edited by: Lily