Adults with pre-existing diabetes have been identified as being more vulnerable to severe complications of COVID-19.

Women with existing diabetes in pregnancy should be advised to strictly follow social distancing measures.

At the booking appointment women with pre-existing diabetes should be given the usual advice as outlined in NHS Highland Diabetes in Pregnancy Guideline.  The need to limit visits to hospital and out of home during the COVID-19 pandemic should be emphasised.

Referral to the Obstetric Diabetes antenatal service should be made in the usual way and arrangements for telephone, NHS Near Me or face-to-face review will be made as appropriate by the obstetric and diabetes teams in consultation. Women with pre existing diabetes should be referred to the diabetes specialist nurse and then offered an appointment with the multidisciplinary obstetric diabetes team to ensure optimum glycaemic control. It is likely that early face-to-face review will be recommended around  the 11-14 week dating scan and if possible these should happen on the same day. Ideally the result of early booking blood will be available at that appointment. Discussion will cover:

• Blood glucose monitoring (continuous monitoring or sensor or finger prick) and the process for remote review of blood glucose control.

Full download of insulin pump data and review by insulin pump team

• Appropriate prescriptions for blood glucose and/or ketone monitoring, and medications which should be obtained by repeat prescription through primary care.

Assessment by Specialist Diabetes Dietician

• Provision of additional materials to support blood glucose monitoring, diet and sick day rules (written and/or online).
• Information on hypoglycaemia avoidance and awareness for women using insulin. Reminder of driving regulations.
• Prescription for folic acid 5mg and low dose aspirin 150mg.
• Home blood pressure monitoring / urinalysis if available.
• Plans for additional bloods to monitor glycaemic control, aiming to keep HbA1c <48mmol/mol.
• Care planning which involves the diabetes specialist nurse or midwife.

There is likely to be reduced access to retinal screening and therefore this should be offered to women with relevant eye symptoms or known retinal changes prior to pregnancy.

Review of home capillary blood sugar levels should be undertaken by e mail or telephone (as is the current practice) by the diabetes team.

Women should continue to have routine antenatal care with their midwifery team where possible.

The joint obstetric diabetes team should aim to review women as a minimum at 20, 28, 32 weeks.  It may be necessary to schedule some or all of these appointments as face to face antenatal appointment depending on the clinical situation and assessment of risk.

Some of these appointments may be suitable for remote review by telephone or NHS near me after community midwifery review.

Some of these appointments may be suitable for remote review by telephone or NHS near me after ultrasound examination in Caithness.

The joint obstetric diabetes team should review women at 36 weeks gestation to assess maternal and fetal condition and plan timing and mode of birth.  It is likely this meeting will be a face to face antenatal appointment.

Additional scans and / or face to face visits may be required as determined by assessment of individual clinical situations.

Regular phone or email communication between obstetric, diabetes and community midwife teams will be essential to plan care and follow-up.

Women affected by COVID-19 and who are symptomatic should be aware of the potential effects of infection on blood sugar control will need more frequent review of home capillary blood sugars and ketones (where appropriate.  All pregnant women with diabetes should be advised of this.

Screening for Gestational Diabetes

To avoid unnecessary visits to hospital and to conserve community resources constraints, a 2-hour oral glucose tolerance test (OGTT) is not recommended as standard for screening. Women meeting the screening criteria for GDM should have:

1. A random blood glucose and HBA1c at booking.

• Women with HbA1c ≥48 mmol/mol or a random plasma glucose ≥11.1mmol/L at booking should be managed as having type 2 Diabetes.
• Women with borderline HbA1c 41-47 mmol/mol or a random plasma glucose 9 -11 mmol/L at booking should be managed as GDM.
• At 28 weeks’ gestation high-risk women whose glucose results at booking were normal should have repeat HbA1c and either fasting (preferred) or random blood glucose.
• Women with HbA1c ≥39 mmol/mol, fasting plasma glucose ≥5.1 mmol/L, or random plasma glucose ≥9 mmol/l should be managed as GDM.
• At any time in pregnancy women with ≥ 2+ glycosuria, nocturia, thirst, polydipsia, large for gestational age or polyhydramnios on ultrasound should be tested for GDM with fasting Glucose and HbA1c.
• Women with HbA1c ≥39 mmol/mol, fasting plasma glucose ≥5.1 mmol/L should be managed as GDM.

Antenatal care for women diagnosed with Gestational Diabetes

Women diagnosed with GDM should be offered a telephone appointment with the diabetes specialist team for discussion of their diagnosis and management .  They will be sent a glucose meter and written education material including links to training videos.  They will be provided with details on how their diabetes will be managed remotely and how to contact individual members of the diabetes team if required.

Women should be followed-up by the diabetes specialist and obstetric teams in liaison with the community midwifery team.  Most of these appointments will be undertaken remotely.

Routine antenatal care including serial measurement of fundal height should continue as normal with the community midwifery team.

GDM on Diet

Women with diet-controlled GDM with blood glucose levels consistently in the target range (fasting: below 5.5mmol/l; 2 hours after meal: below 7mmom/l up to 35 weeks and below 8mmol/l after 35 weeks), normal SFH measurement and no other concerns do not require further hospital visits or ultrasound scans for fetal growth.

Women will be asked to send results to the specialist diabetes team by email weekly for review. 

Community midwives are not expected to routinely check the mother’s blood glucose readings but may need to inform and support mothers on occasion.

GDM on Metformin and / or Insulin

Women with GDM and taking Metformin and /or Insulin should have obstetric diabetes review at 30 and 34 weeks gestation.  These consultations will normally take place by telephone or NHS Near Me and should be guided by the assessment from a recent community midwifery review.

Where women have additional risk factors, poorly controlled blood sugars, acceleration on SFH measurement or other relevant concerns then face-to-face obstetric diabetes review following ultrasound scan for growth is indicated.  This should be requested by the responsible obstetric consultant. 

A final obstetric diabetes review is required at 36 - 37 weeks.  A plan for mode and timing of delivery, and for follow up until delivery should be made.  This consultation may be undertaken remotely and should be guided by assessment from a recent community midwifery review.  Ultrasound to assess fetal growth and wellbeing may be indicated in which case face to face review can be undertaken at same visit. 

Postnatal

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

Sources of information which pregnant women with diabetes might find useful during the COVID-19 pandemic have been listed below.

References:

1. Guidance for Maternal Medicine Services in the evolving Coronavirus (COVID-19) Pandemic.  April 2020:  RCOG.
2. National Institute for Health and Care Excellence. Diabetes in pregnancy: anagement from preconception to the postnatal period, 2015.
3. Covid-19 Information Governance advice for health and care professionals 2020 (Available from: https://www.nhsx.nhs.uk/key-information-and-tools/information-governance-guidance/health-care-professionals) accessed 28 March 2020.Guidance for Maternal Medicine Services in the evolving Coronavirus (COVID-19) Pandemic.  April 2020:  RCOG.

Other Resources for patients:

Gestational diabetes treatment https://www.nhs.uk/conditions/gestational-diabetes/treatment/

Type 1 diabetes in pregnancy http://www.perinatal.nhs.uk/diabetes/projects/leaflets/Sick_Days_Type1.pdf

Continuous glucose monitoring for women with Type 1 diabetes https://abcd.care/dtn/CGM

Avoiding hypoglycaemias in pregnancy http://www.perinatal.nhs.uk/diabetes/projects/leaflets/How_to_avoid_Hypoglycaemia_in_Pregnancy.pdf

Metformin treatment in pregnancy http://www.perinatal.nhs.uk/diabetes/projects/leaflets/Metformin_Treatment_in_Pregnancy.pdf

Postnatal care of women with diabetes http://www.perinatal.nhs.uk/diabetes/projects/leaflets/Post_Natal_Care_for_Gestational_Diabetes.pdf

Breastfeeding your baby and diabetes https://www.youtube.com/watch?v=gXYNj0pWCk0
http://www.perinatal.nhs.uk/diabetes/projects/leaflets/Diabetes_Breastfeeding.pdf