The mainstay of gestational diabetes mellitus (GDM) management is dietary therapy, exercise, and self-monitoring of blood glucose. Nutritional management focuses on a carbohydrate-restricted diet consisting of 35%–40% of calories from carbohydrates and the remainder of calories divided between protein (20%) and fat (40%). The general recommendation for daily glucose monitoring is four times daily performed as fasting and either 1 or 2 hours after the beginning of each meal. The American Congress of Obstetricians and Gynecologists endorses glycemic targets of a fasting glucose ≤95 mg/dL, 1 hour postprandial ≤140 mg/dL, and 2 hour postprandial ≤120 mg/dL as measures of adequate control. 1 The American Diabetes Association endorses similar pre- and postprandial levels. 2 These thresholds have been extrapolated from recommendations for pregnant women with pregestational diabetes. Institution of strict glycemic control has been demonstrated to reduce neonatal morbidity and mortality associated with the diabetic pregnancy by decreasing the incidence of stillbirth and macrosomia. 3 , 4 Infants born to women with well-controlled diabetes also have fewer neonatal complications such as respiratory distress syndrome, hypoglycemia, and hyperbilirubinemia. 5 Treating GDM has also shown maternal benefit including a decrease in hypertensive disorders of pregnancy, and in one trial, a reduction in cesarean delivery was observed. 6 Approximately, 50% of women will meet these glycemic target values within the first 2 weeks of dietary therapy, but only an additional 10% will achieve euglycemia by the fourth week. 7 Most clinicians use this time frame to determine dietary failure and to initiate pharmacologic therapy. There is no conclusive evidence for the threshold number of blood glucoses above target or the absolute blood glucose value at which a clinician should initiate pharmacologic therapy. 8 In our practice, if more than a third of finger-stick glucoses are above the target range, pharmacologic therapy is initiated.