Recommendations and management of hyperglycaemia in pregnancy during COVID-19 pandemic in Italy

Abstract

Many specialists use the remote management of people with chronic disease as diabetes, but structured management protocols have not been developed yet. The COVID-19 pandemic has given a big boost to the use of telemedicine, as it allows to maintain the physical distance, essential to the containment of contagion having regular health contact. Encouraging results related to the use of telemedicine in women with hyperglycaemia in pregnancy, have been recently published. It is well known that hyperglycaemia alters the immune response to infections, that inflammation, in turn, worsens glycaemic control and that any form of hyperglycaemia in pregnancy (HIP) has effects not only on the mother but also on development of the foetus. Therefore, the Italian Diabetes and Pregnancy Study Group, together with a group of experts, developed these recommendations in order to guide physicians in the management of HIP, providing specific diagnostic, therapeutic and assistance pathways (PDTAs) for the COVID-19 emergency. Three detailed PDTAs were developed, for type 1, type 2 and gestational diabetes.

Keywords: COVID-19; GDM; Telemedicine; Type 1 diabetes; Type 2 diabetes.

Fig. 1

Management of pregestational diabetes during COVID-19 pandemic. In the event of unscheduled pregnancy in T2DM, suspend, if in progress, lipid-lowering therapy with statins or antihypertensive drugs contraindicated during pregnancy. In the case of T2DM diagnosed at the beginning of pregnancy, consider as valid the indications reported in the pregestational diabetes section; Chronic complications should also be assessed in these patients. ^§ Instructions for Apps to monitor and share capillary blood glucose data, continuous glucose monitoring and sensor/insulin pump therapy reports (SAP). MySweetGestation and MyGDMoving are free APPs designed by GDS Diabetes and Pregnancy AMD-SID able to supply GDM information. Telemedicine establishes a remote contact with the patient for collecting information related to her health status, the ability to follow the nutritional indications provided and to perform physical activity. The patient must necessarily send the results of weight, PA, glycaemia and ketonemia measurement together with the results of haematological tests, instrumental investigations and obstetrical examinations performed using specific APPs or by sending written documentation to the e-mail address of the centre or to the diabetologist of reference. In case of cough, fever, flu symptoms or in case of positivity to coronavirus infection or quarantine status, the examination must necessarily be performed by telemedicine visit. In the case of coronavirus infection and/or presence of other infective pathologies, it is reiterated the.

Fig. 2

Management of gestational diabetes treated with nutritional medical therapy during COVID-19 pandemic. ^& Plasma ketones monitoring should be carried out at fasting before breakfast at the beginning of diet therapy, in women with obesity (BMI > 30 kg/m² before pregnancy) and in case of poor adherence to nutritional therapy with insufficient intake of complex carbohydrates at the evening meal or in case of prolonged night fasting. ^§ Given the need to reduce the number of accesses to the clinic, it is recommended to provide the patients with the instructions regarding possible subsequent need of insulin therapy and to indicate it in the clinical report for the GP and for the gynaecologist in case at the OGTT, all plasma glucose values are out of target or if 1-hour OGTT plasma glucose is greater than 200 mg/dl. ^Ç MySweetGestation and MyGDMoving are free APPs designed by GDS Diabetes and Pregnancy AMD-SID able to supply GDM information. ^‡ target for fasting glucose < 90 mg/dl and 1 h after beginning meals < 130 mg/dl. ^# Diet therapy should be modified during pregnancy according to weight gain and gestational age. The telemedicine visit should be scheduled every 2–3 weeks in relation to metabolic control; in this occasion all clinical and laboratory parameters and any foetal ultrasounds exam available should be reviewed. It may be appropriate to plan a diabetes evaluation in the same day of an obstetric visit (if the two clinics are located in the same facility). * Evaluate the need to return the patient to the centre before starting insulin therapy. Telemedicine establishes a remote contact with the patient for collecting information related to her health status, the ability to follow the nutritional indications provided and to perform physical activity. The patient must necessarily send the results of weight, PA, glycaemia and ketonemia measurement together with the results of haematological tests, instrumental investigations and obstetrical examinations performed using specific APAs or by sending written documentation to the e-mail address of the centre or to the diabetologist of reference. In case of cough, fever, flu symptoms, in case of positivity due to coronavirus infection or quarantine status, the exposed protocol remains valid, however the patient must be evaluated and instructed in telemedicine by video call. The necessary self-monitoring material, documentation and informative brochures will be provided to the patient through the support of the corporations responsible for the social and health support available in each region. In the case of coronavirus infection and/or presence of other infective pathologies, it is reiterated the need for strict glycaemic monitoring and ketonemia, if appropriate, in order to reach an adequate metabolic control.

Fig. 3

Management of gestational diabetes treated with insulin therapy during COVID-19 pandemic. ^§ Monitoring of plasma ketones must be carried out in the morning before breakfast, particular attention is needed in obese women (BMI > 30 kg/m² before pregnancy) and in case of poor adherence to nutritional therapy during pregnancy with insufficient intake of carbohydrates at the evening meal or in case of prolonged night fasting. In the pre-delivery period, the control of ketones is useful to avoid the onset of metabolic acidosis induced by ketosis due to the metabolic stress of active birth or secondary to prolonged fasting even in case of euglycemia. ^‡ Fasting blood glucose target < 90 mg/dl and 1 h after meals < 130 mg/dl. ^# In case of greatly altered glycaemic values and in case of doubts on the patient’s actual ability to follow the therapeutic indications provided, it may be useful to plan a further visit to the centre in order to check the patient’s skills and the ability in management of the therapy. ^□αMySweetGestation and MyGDMoving are free APPs designed by GDS Diabetes and Pregnancy AMD-SID able to supply GDM information. Telemedicine establishes a remote contact with the patient for collecting information related to her health status, the ability to follow the nutritional indications provided and to perform physical activity. The patient must necessarily send the results of weight, PA, glycaemia and ketonemia measurement together with the results of haematological tests, instrumental investigations and obstetrical examinations performed, using specific APAs or by sending written documentation to the e-mail address of the centre or to the diabetologist of reference. In case of cough, fever, flu symptoms or in case of positivity to coronavirus infection or quarantine status, the examination must necessarily be performed by telemedicine visit. In the case of coronavirus infection and/or presence of other infective pathologies, it is reiterated the need for strict glycaemic monitoring and ketonemia, if appropriate, in order to reach an adequate metabolic control.