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Gestational diabetes mellitus (GDM) is a common metabolic complication of pregnancy and is associated with an increased risk of short-term adverse maternal and neonatal outcomes, as well as long-term metabolic disorders in both mothers and offspring. Exacerbated insulin resistance and inadequate compensatory pancreatic β-cell function constitute the core pathophysiological basis of GDM. Adiponectin is an insulin-sensitizing adipokine that plays important roles in glucose and lipid metabolism, inflammatory regulation, and energy homoeostasis. Changes in maternal circulating adiponectin levels during pregnancy are closely associated with reduced insulin sensitivity and increased risk of GDM. This review systematically summarizes the roles of adiponectin and its distinct isoforms, particularly high-molecular-weight adiponectin, in GDM development, metabolic regulation, and early risk assessment. We also integrate potential interactions between adiponectin and placental hormones, nutrient transport, local inflammation, oxidative stress, and exosome-related mechanisms. In addition, this review discusses the key issues related to adiponectin measurement standardization, gestational timing of blood sampling, population heterogeneity, combined prediction models, and their integration into the oral glucose tolerance test (OGTT). The current findings support adiponectin as a candidate biomarker for early GDM risk stratification and combined prediction models; however, adiponectin cannot replace OGTT as a diagnostic criterion.