[CG] Diabetes Contingency 1: 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 12/10/2020 (for COVID ‐19 pathways)Diabetes: Screening for gestational diabetes GGC (COVID contingency)

12/10/2020

 

Revision of gestational diabetes criteria and diagnosis from 12/10/2020 (for COVID ‐19 pathways) Diabetes: Screening for gestational diabetes GGC (COVID contingency) 12/10/2020

At booking

BMI >= 35 (Clyde, PRM)   BMI >=40 (QEUH)

Previous baby > 4.5 Kg

Family history of diabetes {T1 or T2 in first degree relative}

Family origin {South Asia, Middle Eastern, Chinese or Black African/Caribbean}

Previous Pancreatitis

Previous gestational diabetes {needs FBG at 16 and 26 weeks}

Perform  HA1c at booking

If 48 refer direct into combined clinic

If < 48 perform FBG at 26 weeks gestation in day care ( Previous GDM FBG also at 16 weeks) – From 12/10/20 arrange OGTT rather than FBG on PRM patients.

During the pregnancy

Repeated {> one occasion} heavy glycosuria {2+ or more}

Polyhydramnios

EFW > 97th centile (Intergrowth)

Perform FBG in day care (From 12/10/20 perform OGTT for PRM patients)

Diagnostic for gestational diabetes if FBG > = 5.1 mmol/L (OR 2 hour BG >=8.5mmol/L if OGTT being performed) 

How women with GDM is managed varies between the 3 hospitals – see their individual contingency guidelines

 

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.

Advice for DSN's and dieticians

After referral

  1. To allow as little face to face contact as possible it would be ideal if patient can be e-mailed beforehand with
    1. general advice on gestational diabetes: at MyDiabetesMyWay: https://www.mydiabetesmyway.scot.nhs.uk/  and elearning with mydiabetesmyway :  https://elearning.mydiabetesmyway.scot.nhs.uk/
    2. online training for specific meter you are going to use eg agamatrix.co.uk/support/videos
  2. Patients appointed to single appointment face to face session- if possible using Bluetooth meter and connecting to diasend.
  3. Follow up phone contact from dietetics to reinforce advice.

Antenatal Care

For patient safety and to ensure a fail-safe opportunity to review blood test results and provide appropriately timed antenatal checks all women should continue with their initial planned antenatal care pathway until this is directed otherwise following review by the obstetric-diabetic team.

In addition to this:

  1. women diagnosed with new diabetes / diabetes in pregnancy – for this purpose HbA1c≥48mmol/mol at any time in pregnancy or random glucose ≥11.1 mmol/l – seen as new patient at the appropriate Wednesday morning diabetic-obstetric clinic within 2 weeks. If attending after 26 weeks gestation this should be with a booked growth scan.
  2. women diagnosed with gestational diabetes at booking should be referred to the DSN and dietitian as above and should be offered a review in the diabetic-obstetric clinic at 20 weeks to receive an individualised obstetric shared care plan.
  3. women diagnosed with gestational diabetes at 26-28 weeks should be referred to the DSN and dietitian as above and should be offered a review in the diabetic-obstetric clinic at 30 weeks with a planned growth scan (if not already performed within 4 weeks) to receive an individualised obstetric shared care plan.
  4. Women diagnosed with gestational diabetes before 35+0 weeks due to polyhydramnios/fetal macrosomia or persistent glycosuria should be referred to the diabetic clinic within 7 days with a scan (if not performed within 2 weeks).
  5. Women with gestational diabetes 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. At other times (Monday-Friday 9-4pm):
    1. GGH: gg-uhb.northwestglasgowdiabeteshub@nhs.net and mobiles GGH 1 (Consultants) 07943 585890, GGH (DSNs)  07943 585907
    2. QEUH/Victoria gg-uhb.southglasgowdiabeteshub@nhs.net 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 MyDiabetesMyWay: https://www.mydiabetesmyway.scot.nhs.uk/

and elearning with mydiabetesmyway : https://elearning.mydiabetesmyway.scot.nhs.uk/

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

 

COVID 19 and Combined Obstetric Diabetic Clinics: Revised plan for management within diabetes antenatal clinic QUEEN ELIZABETH UNIVERSITY HOSPITAL MATERNITY UNIT

In the current Covid 19 outbreak, OGTT is now not recommended due to the need to minimise patient contacts. The diabetes/ endocrine obstetric clinics is converting to as much remote working as possible.

Contacts QEUH:

  1. At time of usual Wednesday morning antenatal clinics at QEUH which will continue throughout
  2. At other times (Monday‐Friday 9‐4pm):
    1. GGH: gg‐uhb.northwestglasgowdiabeteshub@nhs.net and mobiles GGH1 (Consultants) 07943 585890, GGH2 (DSNs) 07943 585907
    2. QEUH/Victoria gg‐uhb.southglasgowdiabeteshub@nhs.net and mobiles Vic1 (Consultants) 07943 585877, Vic2 (DSNs) 07943 585884

Advice for DSN’s and dieticians

After referral

To allow as little face to face contact as possible it would be ideal if patient can be e- mailed beforehand with:

  1. general advice on gestational diabetes: at MyDiabetesMyWay: https://www.mydiabetesmyway.scot.nhs.uk/ and elearning with mydiabetesmyway : https://elearning.mydiabetesmyway.scot.nhs.uk/
  2. online training for specific meter you are going to use eg agamatrix.co.uk/support/videos
  3. Patients appointed to single appointment face to face session- if possible using Bluetooth meter and connecting to diasend.
  4. Follow up phone contact from dietetics to reinforce advice.

Antenatal Care

For patient safety and to ensure a fail-safe opportunity to review blood test results and provide appropriately timed antenatal checks all women should continue with their initial planned antenatal care pathway until this is directed otherwise following review by the obstetric-diabetic team.

In addition to this:

  1. women diagnosed with new diabetes / diabetes in pregnancy – for this purpose HbA1c≥48mmol/mol at any time in pregnancy or random glucose ≥11.1 mmol/l – seen as new patient at the appropriate Wednesday morning diabetic-obstetric clinic within 2 weeks. If attending after 26 weeks gestation this should be with a booked growth scan.
  2. women diagnosed with gestational diabetes at booking should be referred to the DSN and dietitian as above and should be offered a review in the diabetic-obstetric clinic at 20 weeks to receive an individualised obstetric shared care plan.
  3. women diagnosed with gestational diabetes at 26-28 weeks should be referred to the DSN and dietitian as above and should be offered a review in the diabetic-obstetric clinic at 30 weeks with a planned growth scan (if not already performed within 4 weeks) to receive an individualised obstetric shared care plan.
  4. Women diagnosed with gestational diabetes before 35+0 weeks due to polyhydramnios/fetal macrosomia or persistent glycosuria should be referred to the diabetic clinic within 7 days with a scan (if not performed within 2 weeks).
  5. Women with gestational diabetes 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.

 

Last reviewed: 12 October 2020

Next review: 01 October 2022

Author(s): R Maitland, J Gibson, MA Ledingham