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Objective To investigate the relationship between disposition index (DI) and the risk of adverse pregnancy outcomes in women with gestational diabetes mellitus (GDM). Methods A total of 1 912 women were prospectively recruited from January 2015 to December 2017 in Department of Gynecology and Obstetrics of the Shanghai Jiao Tong University of Medicine Affiliated Sixth People's Hospital. According to whether they had GDM, they were divided into GDM group (434 cases) and non-GDM group (1 478 cases). All participants received a 75 g oral glucose tolerance test (OGTT) during the 24-28 gestational weeks and complete basal and delivery information was collected. The insulin sensitivity index (ISI) and the area under the insulin curve/area under the blood glucose curve (AUCINS120/AUCGLU120) were calculated from the results of the 75 g OGTT. The DI was calculated as the product of the ISI and AUCINS120/AUCGLU120 and then log transformed. Adverse pregnancy outcomes were defined as large for gestational age (LGA), primary cesarean section, preeclampsia, and preterm birth. Comparison between groups was performed by t test, Wilcoxon rank sum test and χ² test. Logistic regression analysis was used to explore the relationship between DI and the risk of adverse pregnancy outcomes. Results Women with GDM had a lower ISI even DI than women without GDM. Compared with women with GDM in the lowest quartile (Q1, DI<2.90) of DI, multivariable adjusted (age, body mass index, other pregnancy complications, gestational age at the time of OGTT, fetal sex and parity) odds ratios (OR) of adverse pregnancy outcomes of those in the second (Q2, DI 2.90-3.02), third (Q3, DI 3.03-3.16), and highest (Q4, DI>3.16) quartiles of DI were reduced by 55% (95%CI 0.23-0.87), 34% (95%CI 0.35-1.25), and 59% (95%CI 0.24-0.71) (P for trend=0.01), respectively. When DI was considered as a continuous variable, the multivariable adjusted OR of adverse pregnancy outcomes in women with GDM was reduced by 60% (95%CI 0.21-0.73) for each one unit increase in DI. However, DI was not associated with adverse pregnancy outcomes in women without GDM (OR=0.66, 95%CI 0.36-1.18). Conclusion Elevated DI levels in women with GDM are closely associated with a reduced risk of adverse pregnancy outcomes. [ABSTRACT FROM AUTHOR]