Purpose <p>To evaluate whether a fetal growth-guided management strategy can reduce treatment intensity without compromising maternal and neonatal outcomes in women with gestational diabetes mellitus (GDM).</p> Methods <p>This retrospective cohort study with propensity score matching was conducted at a single tertiary referral center and included 343 women with GDM diagnosed after a second-trimester OGTT, of whom 244 were included in the matched analysis. Participants were managed either with a fetal growth-guided approach, in which glycemic targets and insulin therapy were tailored according to fetal abdominal circumference (AC), or with standard glycemia-based care. In the growth-guided group, stricter targets were applied when AC exceeded the 70th percentile. Outcomes were analyzed in the overall cohort and after matching. Primary outcomes were insulin use and glycemic control. Secondary outcomes included maternal weight gain, obstetric outcomes, and neonatal outcomes such as birthweight, Apgar score, cord blood pH, and size for gestational age.</p> Results <p>In the overall cohort, fetal growth-guided management was associated with lower birthweight (3470&#xa0;g vs 3544&#xa0;g; p = 0.036), reduced basal insulin use (58% vs 83%; p &lt; 0.001), lower total insulin dose at delivery (9 vs 18&#xa0;IU; p &lt; 0.001), and slightly improved glycemic control. After propensity score matching, basal insulin use (65% vs 80%; p = 0.029) remained lower, while glycemic control, obstetric outcomes, and neonatal outcomes were comparable. The sensitivity analysis restricted to insulin-treated patients ahowed no significant differences between the differently managed groups of patients.</p> Conclusions <p>A fetal growth-guided approach to GDM management reduces insulin requirements without worsening maternal or neonatal outcomes.</p>