[CG] COVID 19 and Combined Obstetric Diabetic Clinics: Revised plan for QUEH diabetes antenatal clinic including contingency plans for gestational diabetes testing

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In the current Covid-19 outbreak, clinics will find it difficult to provide the usual pattern of screening for gestational diabetes.  Formal standalone OGTT is now not recommended due to the need to minimise patient contacts.  However women with gestational diabetes are at increased risk of adverse outcome and a robust plan must be in place to ensure the best possible chance of identifying the women most at risk and ensuring that they are as efficiently as possible given the knowledge and tools to manage their pregnancy risk.

Performing fasting capillary blood glucose levels with combined immediate patient education and provision of home blood glucose monitoring if fasting sugar is abnormal (>5.1 mmol/l) will identify 2/3 of women who would have been identified by a formal GTT, an increased number of women than identified with HbA1c and random blood sugars and will satisfy equality and diversity requirements for access to care. This has been set up and has been running efficiently at QEUH since 01/04/2020.

If diabetes in pregnancy is diagnosed please refer to QEUH version COVID 19 ANTENATAL CARE MANAGEMENT document to aid an ongoing care pathway.

 

Revision of gestational diabetes criteria and diagnosis from 01/04/2020 (for COVID -19 pathways)

First trimester

At booking in women with risk factors (BOX 1) perform HbA1c + random glucose.  All women with risk factors given access to online resources on healthy eating in pregnancy with advice that routine screening may not be available e.g.

https://www.nhsinform.scot/ready-steady-baby/pregnancy/looking-after-yourself-and-your-baby/eating-well-in-pregnancy

Box 1. Risk factors (Not including previous GDM see box 3)

  • BMI >= 40 kg/m2 at booking*
  • Previous pancreatitis
  • First degree relative with diabetes (sibling , parent, child NOT grandparent)
  • Previous macrosomic baby weighing 4.5kg or above
  • Family origin with high prevalence of diabetes (South Asian/black Caribbean/Middle eastern)

    *Reflects resource differences between sites

Box 2. Interpretation at booking

If HbA1c ≥ 48mmol/mol or random glucose ≥ 11.1 mmol/l  then treat as pre-existing diabetes and refer to diabetic service

If HbA1c 41-47 or random glucose 9-11 mmol/ then treat as GDM, refer to diabetes teams

All others, book capillary fasting BS in Day care with diabetic care practitioner at 26-28 weeks

 

Box 3   Women with previous GDM

Check HbA1c + fasting blood sugar at booking

If HbA1c ≥ 48mmol/mol or random glucose ≥11.1 mmol/l then treat as pre-existing diabetes

If HbA1c 41-47 or random glucose 9-11 mmol/ then treat as GDM, refer to diabetes teams

All others, book capillary fasting BS in Day care with diabetic care practitioner at 16 weeks and at 26-28 weeks

 

At any point in pregnancy if clinical concern (Box 4) then random glucose and HbA1c  

Box 4

Baby with AC / EFW >95th centile 
Polyhydramnios
Fasting glycosuria (>=2+)

Interpretation of HbA1c in third trimester

If HbA1c ≥48 then treat as pre-existing diabetes,

If HbA1c 39-47 then treat as GDM
If random glucose ≥ 9.0 mmol/l then treat as GDM

 

Women with gestational diabetes diagnosed prior to 35 weeks should be referred to the diabetic service. Women diagnosed after 35+0 weeks gestation due to fetal macrosomia or polyhydramnios should be seen urgently within their own consultant antenatal clinic within 7 days and have a plan for delivery made including assessment and discussion of risk of shoulder dystocia and highlighting a plan for the baby to be placed on the neonatal hypoglycaemia pathway after delivery.

After pregnancy: for women felt to be at high risk of diabetes immediately after pregnancy (small minority)  follow up will be arranged by diabetes teams. For majority HbA1c at 6 months is suggested .

Contacts

QEUH:

  1. Wednesday antenatal will continue-list will be reviewed to determine who needs to be physically seen
  2. Contact details:
    1. GGH: [email protected] and mobiles GGH 1 (Consultants) 07943 585890, GGH2 (DSNs)  07943 585907
    2. QEUH/Victoria [email protected] and mobiles Vic 1 (Consultants) 07943 585877, Vic 2 (DSNs)  07943 585884

Remote consultation

All teams have implemented this where possible

Note that useful general advice for patients and specific training modules available at

As well as online training for specific meters eg agamatrix.co.uk/support/videos

Last reviewed: 07 April 2020

Next review: 07 April 2021

Author(s): South and West Diabetic Obstetric MDT