Gestational Diabetes and COVID-19

The Royal College of Obstetricians and Gynaecologists [RCOG] have released Guidance for maternal medicine in the evolving coronavirus (COVID-19) pandemic which includes a section on gestational diabetes and COVID-19 [*New update, released 9 April 2020, Version 2].

As there are quite a few differences to diagnosis and care with gestational diabetes I thought I would outline the specific points related to gestational diabetes and COVID-19 in this post to help.

gestational diabetes and COVID19

*UPDATE FOR 9th APRIL, VERSION 2

Gestational diabetes diagnosis

RCOG recommend that pregnant women should not have a 2 hour OGTT to diagnose gestational diabetes, but instead are to be diagnosed with a HbA1c blood test, fasting or random glucose blood test:

In view of the prolonged waiting period in large groups at the hospital, and resource constraints, we do not recommend a 2-hour oral glucose tolerance test (OGTT). For women considered to be at high risk of GDM as
per the NICE guideline, the following modifications could be used as alternatives to OGTT:
• Women with HbA1c ≥48 mmol/mol or a random plasma glucose≥11.1mmol/L at booking should be cared for as having type 2 diabetes.
• Women with borderline HbA1c 41-47 mmol/mol, or random plasma glucose 9-11 mmol/L at booking should be cared for as having GDM
At 28 weeks’ gestation, all remaining high-risk women should have repeat HbA1c and fasting or random blood glucose alongside their 28-week routine antenatal bloods. Fasting glucose is preferable where feasible.
• Women with either HbA1c ≥39 mmol/mol or fasting plasma glucose ≥5.6 mmol/L or random plasma glucose ≥9 mmol/l will be diagnosed to have GDM. Based on resources, clinical capacity and population characteristics, services may offer an alternative fasting plasma glucose threshold of ≥5.3 mmol/L.
Additionally, at any time in pregnancy, women with heavy glycosuria (2+ or above), high clinical suspicion of diabetes (symptoms – nocturia, thirst, polydipsia), or large for gestational age (LGA) / polyhydramnios on ultrasound should be tested for GDM.
Healthcare professionals may consider using risk calculators for predicting GDM, based on routine clinical
information available at the time of booking.

Guidance for maternal medicine in the evolving coronavirus (COVID-19) pandemic, 9 April 2020, Version 2, section 3.2.2.1

Concerns seeing this recommendation is that some women could go undiagnosed with this method as a HbA1c (average blood glucose test over a 13 week period) is not a reliable test in pregnancy hence it is not normally recommended for use in gestational diabetes diagnosis and they are not testing how the body can cope following a high 75g glucose load.

Where possible, if a full GTT is not being offered, I recommend that mothers, especially those who have higher risk factors for developing gestational diabetes, try self-monitoring blood glucose levels at home to build up a picture of their insulin resistance and use this information to show a positive or negative diagnosis

Following a gestational diabetes diagnosis

Under normal circumstances, you would attend hospital following gestational diabetes diagnosis and then in many areas weekly or fortnightly antenatal diabetes clinic appointments to review blood glucose levels with the diabetes team and see a dietician etc. However this guidance has been changed as follows:

All women diagnosed with GDM should have an appointment with the diabetes midwife/nurse, who will provide training in the use of a glucose meter. Where feasible, this should be done remotely via video call. This visit should also be used as an opportunity to provide women with dietetic information and contact details of the dietician, where one is available.
Women should be followed-up remotely in the week after the meter training by the diabetes midwife/nurse and for all appointments where home capillary blood sugar levels are to be checked by the diabetes team.
Routine antenatal care (e.g. measurement of fundal height where indicated, blood pressure and urinalysis) can otherwise continue as normal, ideally with the midwifery team.

Guidance for maternal medicine in the evolving coronavirus (COVID-19) pandemic, 30 March 2020, Version I, section 3.2.2.2
testing blood sugar levels

Different antenatal treatment for diet controlled women

In women who have GDM that is diet-controlled, with blood glucose levels consistently in the target range (as per the NICE guideline), no further hospital visits or ultrasound scans for fetal growth are needed.
Women should be provided with clear guidance on who to contact if they have >3 abnormal blood glucose levels in a week or >10-15% of all readings – this will usually be the diabetes antenatal team. It is possible that services may not be able to contact all women with GDM who are self-monitoring. It is therefore essential that women understand the responsibility of contacting the diabetes team if their readings are outside of the specified targets.
Although community midwives are not expected to routinely check the mother’s blood glucose readings, they should be provided with information on target blood glucose levels to help inform and support the mother, if needed.

Guidance for maternal medicine in the evolving coronavirus (COVID-19) pandemic, 30 March 2020, Version I, section 3.2.2.2

This information is quite concerning as we know that many hospitals do not use the NICE recommended test times and targets (<5.3mmol/L fasting, <7.8mmol/L 1 hour post meals). Therefore if all hospitals follow this advice from RCOG for gestational diabetes and COVID-19 regarding diet control, but are using much higher test targets, infrequent testing, or only pre-meal testing etc. then the mother may remain diet controlled but will not be offered additional growth scans to check baby’s growth.

I recommend that if you have been advised to follow test times or targets which are outside the recommended NICE guidelines (stated above), then it would be advisable to change to following NICE guidance instead and inform your diabetes team for your reasons of doing this

Metformin or insulin controlled women

In women who have GDM and are taking metformin and/or insulin, offer obstetric review remotely at 28 and 32 weeks’ gestation to reassess the risk status. If face-to-face obstetric reviews are needed, for example in women with additional risk factors or poorly controlled blood sugars, ensure that these reviews coincide with any planned ultrasound appointments.
Offer obstetric review at 36 weeks, remotely if possible, to comprehensively assess maternal and fetal condition, plan timing and mode of birth, and plan follow-up care until birth.
As for women with pre-existing diabetes, *antenatal corticosteroids for fetal lung maturation should be given in line with NICE guidelines

Guidance for maternal medicine in the evolving coronavirus (COVID-19) pandemic, 30 March 2020, Version I, section 3.2.2.2

*Steroids for lung maturity

As steroids can cause elevated blood glucose levels, those who require them for fetal lung maturity are often admitted to hospital to monitor their blood glucose levels hourly throughout this time and many require a sliding scale variable rate insulin infusion, therefore I believe from reading this guidance that they will not be offering steroids for lung maturity to diabetic women unless they have been admitted for other reasons

…if birth is planned after 34+0 weeks’ gestation, where the administration of steroids would require additional hospital visits, steroids should be withheld (on the basis that the benefit to the baby at this gestation would not justify the risk to the mother associated with two additional hospital visits). For the same reason, this recommendation also applies to term elective caesarean birth. Women who are already hospital inpatients can be given steroids for fetal lung maturation in accordance with current local policy.

Guidance for maternal medicine in the evolving coronavirus (COVID-19) pandemic, 30 March 2020, Version I, section 3.1.4
Sliding scale insulin UK

Post birth diabetes screening

Post birth diabetes screening has been extended to 6 months post birth

Postnatally, women with GDM can be offered HbA1c screening at 3-6 months after birth instead of the current recommendation of 3 months.

Guidance for maternal medicine in the evolving coronavirus (COVID-19) pandemic, 30 March 2020, Version I, section 3.2.2.2
blood test

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Gestational Diabetes Mums are struggling to get GD staple foods

So what are you supposed to do when you cannot get the food you need and rely on which you know keeps your blood glucose levels lower and your baby safe?

I want to remind all gestational diabetic & diabetic pregnant Mums that this is a condition which ??? be treated with the use of meds or insulin.

Obviously we know that making good dietary choices can make a huge impact on blood glucose levels, but if we cannot obtain specific foods needed to do this then we still have to eat.

Not eating means that blood glucose levels drop low, resulting in the liver dumping glucose into the bloodstream. This means that it is very important to continue eating. All you can do is eat the best you possibly can with the things you have.

TIPS:
  • Apply the 8 Golden Rules to help make what you have is as well paired as possible
  • There may not be wholewheat pasta, but you don’t NEED to eat pasta! Make courgetti instead & then have some oatcakes/Ryvita on the side for a small serving of complex carbs
  • Try local farm stores/smallholders for things like fresh veg, fruit & eggs
  • Reach out to family, friends & your local community to ask for support in swapping or sharing goods if you can too
  • If the limit in a shop is 1 loaf of bread and you need a white loaf for the rest of the family, pick up some wholewheat wraps or crackers for you to have so you don’t need to go completely without

If making these changes means you experience over target blood glucose levels, then please contact your diabetes team for support with Metformin and/or insulin, or increasing doses as necessary.

At times like these we all need to be kind (that includes to yourself!)

Take care, Jo ?