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The pandemic had a significant impact on laboratories, both by limiting the number of people labs can host and by redirecting laboratory staff to pandemic-related issues, Cooper said
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Some concerns are raised about changes in the screening for gestational diabetes mellitus. Getty Images / iStockphoto
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Some pregnant women will be screened differently for gestational diabetes (GDM) during the COVID-19 pandemic. Alternative screening has been introduced in Canada to reduce the risk of pregnant women being exposed to the virus. However, some experts say that many cases of GDM will go undetected with the new guidelines.
GDM is different from type 1 or 2 diabetes, explains Dr. Stephanie Cooper, obstetrician, gynecologist and specialist in maternal-fetal medicine at Alberta Health Services.
During pregnancy, carbohydrates such as bread, rice, and fruit are broken down differently to ensure that the baby receives an adequate supply of sugar. In some cases, the hormones that make this possible cause the mother’s blood sugar to get too high.
“These higher blood sugar levels can cause problems during pregnancy that affect both the mother and the baby,” she said.
Unmanaged GDM can cause the baby to get too much sugar and grow too big, leading to a difficult delivery. It also puts the mother at greater risk of serious infection or injury during delivery. Both mother and baby are at increased risk of developing type 2 diabetes later in life.
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Prior to the pandemic, it was recommended that all pregnant women between 24 and 28 weeks be screened for GDM with a sugar drink test in a laboratory. After drinking a syrupy, sweet liquid, they waited an hour and then had a blood drawn. When a woman’s blood sugar level reaches a certain threshold, she moves on to the oral glucose tolerance test (OGTT) – a fasting test that tests the blood one to two hours after the sugary drink.
However, the pandemic has had a significant impact on laboratories, both by limiting the number of people who can be housed in laboratories and by redirecting laboratory staff to pandemic-related issues, Cooper said. This has made it extremely difficult for women to do these tests. Also, if women wait several hours in the lab, there is a higher risk of contracting the virus.
“I think that certainly drove the consensus group with the endocrinologists and some of the country’s obstetrician-maternal-fetal medicine (specialists) to develop an alternative screening protocol for gestational diabetes and pregnancy,” she said.
In the new screening, which was done in April 2020, pregnant women at low risk of developing GDM have an A1c test and a non-fasting random blood sugar test. Both tests are done in a laboratory but take less than 10 minutes compared to OGTT, which requires pregnant women to be in the laboratory for two hours.
The Society of Obstetricians and Gynecologists of Canada (SOGC) states in their alternative screening report that these tests have high specificity but low sensitivity.
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The test’s high specificity means that it is effective in excluding diabetes but not “excluding in diabetes” very well, said Dr. Claire Meek, a clinical researcher at Cambridge University and a consultant doctor on diabetes in pregnancy.
“It’s good as a ‘no’ test, but not so good at finding people who actually have it,” she said. In fact, Meek said that about 60 to 80 percent of women with GDM would miss the tests.
“We recognize that this alternative screening option will be missed by many women with GDM,” the SOGC report said. “This strategy aims to identify only the women at greatest risk.”
Under normal circumstances, Meek said a study would be done to look at what happens to women who are not properly identified with GDM and to determine what thresholds should be, who should be tested for GDM, and Not. However, due to the rapid pace of the pandemic, this was not done.
“In fact, this limit was chosen for health care needs rather than women, and I think that’s a big challenge,” she said.
Cooper added that these tests also lead to many false negative results. As a result, SOGC determined that the new screening only applies to women who do not meet risk factors for developing GDM. Women at high risk of developing GDM still have more extensive screening, including the sugar drink test and OGTT. However, the OGTT is now more of a one-hour test than a two-hour test.
Factors that make women more likely to develop GDM include a family history of diabetes, high body weight or obesity, and being over 35 years of age. Women who are South Asian, Hispanic, and Black are also at increased risk.
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“The goal is not to miss the women who are at significant risk of pregnancy complications until laboratory resources return to normal (and) we can revert to best-established protocols based on the expert opinion and evidence available.” Said Cooper.
One risk for expectant mothers who do not know they have GDM is their inability to make the dietary changes necessary to reduce their risk of developing a large baby. In rare cases, unmanaged GDM can also lead to stillbirth. In fact, Meek said that with alternative screening there will be more stillbirths from undiagnosed GDM than from maternal COVID-19.
Christine Jennings, mother of two, developed GDM during both of her pregnancies. She was shocked by the diagnosis; Like many first-time women, she had expected her pregnancy to progress easily with few, if any, complications.
Christine Jennings / Photo provided by Christine Jennings
“It was difficult at first, mostly because I rebelled against my anger and bitterness and now felt like I had to manage myself during the day,” she said.
The first thing Jennings had to do then – 10 minutes after waking up in the morning – was to prick her fingertip with a lancing device and let a tiny drop of blood come to the surface. She would then hold the edge of a test strip against the blood and a glucometer would show her empty blood sugar level. Two hours after breakfast, lunch, dinner, or a meal, she repeated this process.
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Jennings stated that if levels stayed within a normal range, GDM could be managed with dietary changes alone. Despite eating a healthier diet, two weeks after her initial diagnosis, her readings were still too high and she had to start injecting insulin.
Every night before bed, after Jennings had set her insulin needle to the correct dose, she pinched off a small roll of belly fat and injected the tiny needle into her skin. She continued like this until her daughter was born at forty-one weeks.
Often times, pregnancy is induced for about 38 weeks in women with GDM if their blood sugar levels are not under control. This will reduce the baby’s risk of growing too tall and causing complications during delivery. Jennings noted, however, that her levels were manageable and her daughter was born a healthy eight pounds.
According to Jennings, screening women at highest risk for GDM makes sense, and ultimately, the most important factor during pregnancy is quality care.
The guidelines state that regular GDM screening “can continue if there is minimal impact on the capacity for laboratory testing or treating GDM,” and Cooper said some rural areas with few COVID-19 cases are failing to comply had to adapt alternative guidelines. However, Calgary’s high case numbers have not made this an option.
Cooper said that while low-risk women are screened with a less comprehensive test, there are other ways to detect potential GDM throughout pregnancy.
“It’s not that not taking the test will completely rule out (low risk women). We’re still paying attention to some of the potential concerns. “
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