Objective To explore the efficacy of serum free estriol (FE3), adiponectin (ADP) and fetal aortic isthmus (AOI) parameters in predicting complications of fetal distress (FD) in gestational diabetes (GDM). Methods The clinical data of 150 patients with GDM from January 2019 to October 2020 were reviewed. According to whether FD occurred, they were divided into FD group (37 cases) and non-FD group (113 cases). In addition, 75 cases of normal pregnancy in the same period were selected as Control group. Compare the differences in serum FE3, ADP and AOI parameters (IFI, ISI) of the three groups of patients, apply Pearson correlation to analyze the relationship between FE3, ADP, IFI, ISI, establish receiver operating characteristics (ROC) curves, and explore FE3, ADP, IFI, ISI and the four joint forecasts of the value of GDM concurrent FD. Results FE3, ADP, IFI of the FD group were significantly lower than those of the non-FD group and the control group, and ISI was significantly higher than that of the non-FD group and the control group. The differences were statistically significant (all P<0.05); the non-FD group FE3, ADP, IFI was significantly lower than the control group, ISI was significantly higher than the control group, the difference was statistically significant (all P<0.05). Pearson results showed that serum FE3 was significantly positively correlated with ADP (r=0.571, P<0.001), IFI (r=0.648, P<0.001), and significantly negatively correlated with ISI (r=-0.629, P<0.001) ). ADP was significantly positively correlated with IFI (r=0.625, P<0.001), and significantly negatively correlated with ISI (r=-0.539, P<0.001). There was a significant negative correlation between IFI and ISI (r=-0.648, P<0.001). ROC curve analysis shows that the area under the curve AUC of FE3, ADP, IFI, ISI and the four joint predictions of GDM concurrent FD are 0.681, 0.793, 0.727, 0.669, 0.863, respectively. The pairwise Z test results showed that the AUC of ADP was significantly higher than FE3, ISI (all P<0.05), and the four combined AUC were significantly higher than FE3, IFI, ISI (all P<0.05). When the cut-off value is taken, the sensitivities of FE3, ADP, IFI, ISI, and the combination of the four are 90.3%, 56.6%, 90.2%, 90.3%, and 85.8%, respectively; the specificity is 43.2%, 91.9%, and 51.4, respectively %, 37.8%, 86.5%. Conclusion Serum FE3, ADP, and fetal IFI in patients with GDM complicated by FD are significantly reduced, and fetal ISI is increased. Monitoring the changes in FE3, ADP, and fetal IFI and ISI levels may predict GDM complicated by FD.