Objective: The aim of the present study was to provide practical considerations for assessing MD adherence during pregnancy based on the association with cardiometabolic risk. Study design: Longitudinal study. Main outcome measures: A food frequency questionnaire was fulfilled by 152 pregnant women at the 16th gestational week (g.w.). We calculated the Mediterranean Food Pattern (MFP), the MD Scale (MDScale), the Short MD questionnaire (SMDQ), the MD Score (MedDietScore), and the MD scale for pregnant women (MDS-P). The cardiometabolic risk score consisted of pre-pregnancy body mass index, blood pressure, glucose, tri-glycerides, and high-density lipoprotein-cholesterol (at 16th and 34th g.w.). Results: Multiple linear regression models showed that the MFP, the MedDietScore, and the SMDQ were asso-ciated with lower cardiometabolic risk at the 16th and 34th g.w. (13s:-0.193 to-0.415, all p < 0.05); and the MDS-P at the 34th g.w. (13 =-0.349, p < 0.01). A comparison of these models with the J test showed that the MFP and the MedDietScore outperformed the SMDQ at the 16th g.w. (ps < 0.05); while the MedDietScore outperformed the SMDQ, MFP, and MDS-P (ps < 0.05) at the 34th g.w. Receiver-Operating-Characteristic-derived thresholds for the MFP, MedDietScore and MDS-P indices were 21, 30, and 6 points, respectively, to identify women with high cardiometabolic risk. Conclusion: The MFP and MedDietScore are recommended to assess MD adherence during pregnancy, as these showed the strongest associations with cardiometabolic risk. Our validated thresholds might assist in the detection of poor dietary patterns during pregnancy.