A 26-year-old pregnant woman with gestational diabetes and fasting plasma glucose of 6 mmol/L; what is the most appropriate initial treatment plan?

• A. Start insulin therapy immediately
• B. Advise changes in diet and exercise for 2 weeks
• C. Prescribe metformin as first-line
• D. Schedule regular obstetric follow-up without dietary changes

Answer: (B)

Managing gestational diabetes starts with lifestyle changes. A fasting glucose of about 6 mmol/L indicates mild hyperglycemia that often responds to nonpharmacologic measures, so the best first step is a structured plan of diet and exercise for a trial period (typically around 1–2 weeks) while monitoring glucose closely. This approach aims to improve insulin sensitivity and reduce fetal exposure to high glucose without exposing mother or fetus to medications unnecessarily.

Practical steps would include a carb-controlled diet spread across meals, appropriate caloric intake to support the pregnancy, and regular physical activity as advised by a clinician. Alongside these changes, frequent home glucose monitoring helps determine whether targets are being met. If glucose targets remain unmet after the trial period—especially fasting levels staying above the guideline targets or significant postprandial elevations—then pharmacologic therapy, such as insulin, can be started. In some settings, clinicians may consider other agents if insulin is not acceptable or available, but starting with diet and exercise is the standard initial approach. Regular obstetric follow-up remains essential throughout.