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Kleinwechter HJ, Weber KS, Liedtke TP, Schäfer-Graf U, Groten T, Rüdiger M, Pecks U. COVID-19, Pregnancy, and Diabetes Mellitus. Z Geburtshilfe Neonatol 2024; 228:17-31. [PMID: 37918833 DOI: 10.1055/a-2180-7715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
During the severe acute respiratory distress virus coronavirus type 2 (SARS-CoV-2) pandemic, many women were infected during their pregnancies. The SARS-CoV-2-induced coronavirus disease 19 (COVID-19) has an impact on maternal health and pregnancy outcomes; peripartum and perinatal morbidity and mortality are increased. Pregnancy is considered a risk factor for severe COVID-19 course. Additional risk factors during pregnancy are diabetes mellitus, gestational diabetes mellitus (GDM), and obesity. Systemic inflammation can lead to severe metabolic dysregulation with ketoacidosis. The endocrine pancreas is a target organ for SARS-CoV-2 and the fetal risk depends on inflammation of the placenta. Up to now there is no evidence that SARS-CoV-2 infection during pregnancy leads to permanent diabetes in mothers or their offspring via triggering autoimmunity or beta cell destruction. The frequently observed increased prevalence of GDM compared to the years before the pandemic is most likely due to changed lifestyle during lockdown. Furthermore, severe COVID-19 may be associated with the development of GDM due to worsening of glucose tolerance. Vaccination with a mRNA vaccine is safe and highly effective to prevent infection and to reduce hospitalization. Registries support offering evidence-based recommendations on vaccination for pregnant women. Even with the current omicron virus variant, there are increased risks for symptomatic and unvaccinated pregnant women.
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Affiliation(s)
| | | | | | - Ute Schäfer-Graf
- Department of Obstetrics, Berlin Diabetes Center for Pregnant Women, St. Joseph Hospital, Berlin, Germany
| | - Tanja Groten
- Department of Obstetrics, Competence Center for Diabetic Women, Jena University Hospital, Jena, Germany
| | - Mario Rüdiger
- Saxony Center for Fetal-Neonatal Health, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ulrich Pecks
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
- Department of Obstetrics, University Hospital Würzburg, Maternal Health and Midwifery Science, Würzburg, Germany
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2
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Stamatiades GA, Galbiati F, Fitzgerald AC, McDonnell ME, Lassey SC, Palermo NE. Diabetes Mellitus Type 1 Presenting in the Setting of Diabetic Ketoacidosis and Acute SARS-CoV-2 Infection in Pregnancy. AACE Clin Case Rep 2023; 9:S2376-0605(23)00091-3. [PMID: 37363439 PMCID: PMC10102535 DOI: 10.1016/j.aace.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/10/2023] [Accepted: 04/10/2023] [Indexed: 06/28/2023] Open
Abstract
Background/Objective Diabetic ketoacidosis (DKA) during pregnancy is an obstetric emergency associated with a higher rate of maternofetal morbidity and mortality. Pregnancy itself is a ketosis-prone state and several unique mechanisms predispose to the development of insulin resistance, which can be further exacerbated by acute stressors such as infection. Thus, pregnant patients who additionally contract COVID-19 may be at an even higher risk of development of DKA. Case Report A 32-year-old patient, with no prior history of impaired glucose tolerance, presented at 27 weeks of gestation with a 3-day history of shortness of breath, congestion, loss of taste and smell, polyuria, and polydipsia. Biochemical evaluation was consistent with DKA. Subsequently, she was diagnosed with acute SARS-CoV-2 infection. Treatment included intravenous hydration, electrolyte replacement, and insulin infusion. Postpartum phenotypic evaluation confirmed autoimmune diabetes (positive GAD-65 and zinc T8 antibodies) with residual β-cell function. Six months postpartum, glycemic control remains at goal with basal- bolus insulin regimen. Discussion This case describes the peculiar ability of SARS-CoV-2 infection to potentially rouse autoimmunity and how COVID-19 and DKA in pregnancy can be particularly challenging given the risk of significant maternal and fetal morbidity and mortality. Conclusion Prompt diagnosis and evaluation of DKA in pregnancy as well as a higher level of suspicion is needed in the setting of SARS-CoV-2 infection. Additionally, this case depicts the need for closely monitoring the postpartum period for patients at risk of autoimmune disease, which may have been blunted in pregnancy.
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Affiliation(s)
- George A Stamatiades
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Francesca Galbiati
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Marie E McDonnell
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah C Lassey
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nadine E Palermo
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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3
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Mohammadzade F, Khodabakhshi B, Amiri E, Bigdeli A, Abdollahi F, Fatemi A. Euglycemic diabetic ketoacidosis and COVID-19 management in a term pregnant patient; a case report. Clin Case Rep 2022; 10:e6705. [PMID: 36483858 PMCID: PMC9723478 DOI: 10.1002/ccr3.6705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 09/09/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
In this case report, we report a Covid-19 infected female patient with gestational diabetes mellitus with primary manifestation of ketoacidosis at term pregnancy and discuss the management challenges with euglycemia and a high ketone burden.
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Affiliation(s)
- Fatemeh Mohammadzade
- Metabolic Disorders Research CenterGolestan University of Medical SciencesGorganIran
| | - Behnaz Khodabakhshi
- Infectious Diseases Research CenterGolestan University of Medical SciencesGorganIran
| | - Elahe Amiri
- Metabolic Disorders Research CenterGolestan University of Medical SciencesGorganIran
| | - Amir Bigdeli
- Department of Nephrology and Hypertension, Sayyad Shirazi HospitalGolestan University of Medical SciencesGorganIran
| | - Fahimeh Abdollahi
- Pulmonary Ward, Department of Internal Medicine, Sayyad Shirazi HospitalGolestan University of Medical SciencesGorganIran
| | - Alireza Fatemi
- Ischemic Disorder Research CenterGolestan University of Medical SciencesGorganIran
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Coad F, Frise C. Considerations for women with COVID-19 admitted to hospital. Obstet Med 2022; 15:233-237. [PMID: 36514794 PMCID: PMC8938185 DOI: 10.1177/1753495x221083504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/09/2022] [Accepted: 02/02/2022] [Indexed: 12/15/2022] Open
Abstract
The number of pregnant women being admitted with severe COVID-19 infection and dying has increased with each wave of the pandemic. These women often present unique challenges to the medical and obstetric teams given the changes in physiology that occur in pregnancy, affecting assessment and management, as well as the practical difficulties such as the ideal location of care. Whilst the basis of treatment remains the same, there are nuances to caring for pregnant women that need considerable thought and multidisciplinary collaboration. Obstetricians, neonatologists, midwives, intensivists, anaesthetists and physicians may all be involved at some point, depending on the gestation and severity of illness. Implementing a COVID-19 in pregnancy guideline or checklist for your hospital will help ensure pregnant women are managed in a safe and timely manner. Here described are some key recommendations to help in the management of pregnant women admitted with COVID-19.
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Affiliation(s)
- Felicity Coad
- Acute Internal Medicine, Royal United Hospital Bath NHS
Trust, Bath, UK,Felicity Coad, Acute Internal Medicine,
Royal United Hospital Bath NHS Trust, Combe Park, Bath, UK.
| | - Charlotte Frise
- Fetal Maternal Medicine Unit and Department of Acute and General
Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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5
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Bereda G. Case Report: Diabetic Ketoacidosis During Pregnancy Due to Insulin Omission. OPEN ACCESS EMERGENCY MEDICINE 2022. [DOI: https://doi.org/10.2147/oaem.s388941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Bereda G. Case Report: Diabetic Ketoacidosis During Pregnancy Due to Insulin Omission. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:615-618. [PMID: 36411797 DOI: 10.2147/oaem.s388941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Gudisa Bereda
- Department of Pharmacy, Negelle Health Science College, Negelle, Oromia Regional State, 1000, Ethiopia
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Harman ML, Cuellar EM, Burkhart Denora AR, Pokhriyal M, Mussarat S. Euglycemic Diabetic Ketoacidosis in a Pregnant Woman With Severe COVID-19: A Case Report. Cureus 2022; 14:e21649. [PMID: 35242454 PMCID: PMC8884461 DOI: 10.7759/cureus.21649] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 11/29/2022] Open
Abstract
Euglycemic diabetic ketoacidosis (DKA) of pregnancy is an uncommon but serious condition that poses a substantial risk to the fetus. The physiological state of pregnancy itself predisposes women to ketosis and ketoacidosis, which can be further exacerbated by acute stressors such as infection. In this article, we describe a case of a pregnant woman with gestational diabetes and coronavirus disease 2019 (COVID-19) requiring mechanical ventilation who developed euglycemic DKA during her hospital course. Despite treating the patient with standard DKA protocol, fetal heart monitoring was non-reassuring and, hence, a cesarean section was performed. Postoperatively, her DKA resolved; however, she was maintained on supportive ventilation for continued management of her severe COVID-19 infection. In light of the ongoing pandemic, it is essential that healthcare teams closely monitor pregnant women presenting with COVID-19 infection for early signs of euglycemic DKA so that treatment may be initiated early and feto-maternal complications are avoided.
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Velasco I, Soldevila B, Julián T, García‐Riaño N, Puig‐Domingo M. Euglycemic diabetic ketoacidosis and COVID-19: A combination to foresee in pregnancy. J Diabetes 2022; 14:88-89. [PMID: 34729932 PMCID: PMC9060032 DOI: 10.1111/1753-0407.13237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 01/10/2023] Open
Affiliation(s)
- Inés Velasco
- Obstetrics & Gynecology DepartmentHospital Universitari Germans Trias i PujolBadalonaSpain
- Germans Trias i Pujol Research InstituteBadalonaSpain
- Medicine DepartmentAutonomous University of BarcelonaBarcelonaSpain
- Endocrinology and Nutrition DepartmentHospital Universitari Germans Trias i PujolBadalonaSpain
| | - Berta Soldevila
- Germans Trias i Pujol Research InstituteBadalonaSpain
- Medicine DepartmentAutonomous University of BarcelonaBarcelonaSpain
- Endocrinology and Nutrition DepartmentHospital Universitari Germans Trias i PujolBadalonaSpain
| | - Teresa Julián
- Germans Trias i Pujol Research InstituteBadalonaSpain
- Medicine DepartmentAutonomous University of BarcelonaBarcelonaSpain
- Endocrinology and Nutrition DepartmentHospital Universitari Germans Trias i PujolBadalonaSpain
| | - Natalia García‐Riaño
- Obstetrics & Gynecology DepartmentHospital Universitari Germans Trias i PujolBadalonaSpain
- Germans Trias i Pujol Research InstituteBadalonaSpain
- Medicine DepartmentAutonomous University of BarcelonaBarcelonaSpain
| | - Manel Puig‐Domingo
- Germans Trias i Pujol Research InstituteBadalonaSpain
- Medicine DepartmentAutonomous University of BarcelonaBarcelonaSpain
- Endocrinology and Nutrition DepartmentHospital Universitari Germans Trias i PujolBadalonaSpain
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9
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Alhumaid S, Al Mutair A, Al Alawi Z, Rabaan AA, Alomari MA, Al Salman SA, Al-Alawi AS, Al Hassan MH, Alhamad H, Al-kamees MA, Almousa FM, Mufti HN, Alwesabai AM, Dhama K, Al-Tawfiq JA, Al-Omari A. Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis. Diabetol Metab Syndr 2021; 13:120. [PMID: 34702335 PMCID: PMC8547563 DOI: 10.1186/s13098-021-00740-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND One possible reason for increased mortality due to SARS-CoV-2 in patients with diabetes is from the complication of diabetic ketoacidosis (DKA). OBJECTIVES To re-evaluate the association of SARS-CoV-2 and development of DKA and analyse the demographic and biochemical parameters and the clinical outcomes in COVID-19 patients with DKA. DESIGN A systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed. METHODS Electronic databases (Proquest, Medline, Embase, Pubmed, CINAHL, Wiley online library, Scopus and Nature) were searched from 1 December 2019 to 30 June 2021 in the English language using the following keywords alone or in combination: COVID-19 OR SARS-CoV-2 AND diabetic ketoacidosis OR DKA OR ketosis OR ketonemia OR hyperglycaemic emergency OR hyperglycaemic crisis. We included studies in adults and children of all ages in all healthcare settings. Binary logistic regression model was used to explore the effect of various demographic and biochemical parameters variables on patient's final treatment outcome (survival or death). RESULTS Of the 484 papers that were identified, 68 articles were included in the systematic review and meta-analysis (54 case report, 10 case series, and 4 cohort studies). Studies involving 639 DKA patients with confirmed SARS-CoV-2 [46 (7.2%) were children and 334 (52.3%) were adults] were analyzed. The median or mean patient age ranged from < 1 years to 66 years across studies. Most of the patients (n = 309, 48.3%) had pre-existing type 2 diabetes mellitus. The majority of the patients were male (n = 373, 58.4%) and belonged to Hispanic (n = 156, 24.4%) and black (n = 98, 15.3%) ethnicity. The median random blood glucose level, HbA1c, pH, bicarbonate, and anion gap in all included patients at presentation were 507 mg/dl [IQR 399-638 mg/dl], 11.4% [IQR 9.9-13.5%], 7.16 [IQR 7.00-7.22], 10 mmol/l [IQR 6.9-13 mmol/l], and 24.5 mEq/l [18-29.2 mEq/l]; respectively. Mortality rate was [63/243, 25.9%], with a majority of death in patients of Hispanic ethnicity (n = 17, 27%; p = 0.001). The odd ratios of death were significantly high in patients with pre-existing diabetes mellitus type 2 [OR 5.24, 95% CI 2.07-15.19; p = 0.001], old age (≥ 60 years) [OR 3.29, 95% CI 1.38-7.91; p = 0.007], and male gender [OR 2.61, 95% CI 1.37-5.17; p = 0.004] compared to those who survived. CONCLUSION DKA is not uncommon in SARS-CoV-2 patients with diabetes mellitus and results in a mortality rate of 25.9%. Mortality key determinants in DKA patients with SARS-CoV-2 infection are individuals with pre-existing diabetes mellitus type 2, older age [≥ 60 years old], male gender, BMI ≥ 30, blood glucose level > 1000 mg/dl, and anion gap ≥ 30 mEq/l.
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Affiliation(s)
- Saad Alhumaid
- Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health, Rashdiah Street, P. O. Box 12944, Al-Ahsa, 31982 Saudi Arabia
| | - Abbas Al Mutair
- Research Center, Almoosa Specialist Hospital, Al-Ahsa, Saudi Arabia
- College of Nursing, Princess Norah Bint Abdul Rahman University, Riyadh, Saudi Arabia
- School of Nursing, University of Wollongong, Wollongong, Australia
| | - Zainab Al Alawi
- Division of Allergy and Immunology, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Ali A. Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, 11533 Saudi Arabia
- Department of Public Health and Nutrition, The University of Haripur, Haripur, 22610 Pakistan
| | | | - Sadiq A. Al Salman
- Division of Neurology, Internal Medicine Department, King Fahad Hofuf Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Ahmed S. Al-Alawi
- Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health, Rashdiah Street, P. O. Box 12944, Al-Ahsa, 31982 Saudi Arabia
| | - Mohammed H. Al Hassan
- Administration of Nursing, Al-Ahsa Health Cluster, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Hesham Alhamad
- Regional Medical Supply, Al-Ahsa Health Cluster, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Mustafa A. Al-kamees
- Primary Care Medicine, Al-Ahsa Health Cluster, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Fawzi M. Almousa
- Department of Pharmacy, Al Jaber Hospital for Eye, Ear, Nose and Throat, Al-Ahsa, Saudi Arabia
| | - Hani N. Mufti
- Department of Cardiac Sciences, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- Department Cardiac Sciences, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- Department of Medical Research, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Ali M. Alwesabai
- Department of Restorative Dentistry, King Faisal General Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Kuldeep Dhama
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Uttar Pradesh, Izatnagar, Bareilly, 243122 India
| | - Jaffar A. Al-Tawfiq
- Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
- Infectious Disease Division, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN USA
- Infectious Disease Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Awad Al-Omari
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Research Center, Dr. Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
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Priya G, Bajaj S, Kalra B, Coetzee A, Kalra S, Dutta D, Lim V, Diwakar H, Deshmukh V, Mehta R, Sahay R, Gupta Y, Sharma JB, Dasgupta A, Patnala S, Afsana F, Giri M, Sheikh A, Baruah M, Asirvatham AR, Sheikh S, Cooray S, Acharya K, Langi YA, Jacob J, Malhotra J, George B, Grewal E, Chandrasekharan S, Nadeem S, Lamptey R, Khandelwal D. Clinical practice recommendations for the detection and management of hyperglycemia in pregnancy from South Asia, Africa and Mexico during COVID-19 pandemic. J Family Med Prim Care 2021; 10:4350-4363. [PMID: 35280627 PMCID: PMC8884306 DOI: 10.4103/jfmpc.jfmpc_653_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 12/02/2022] Open
Abstract
The human coronavirus disease 2019 (COVID-19) pandemic has affected overall healthcare delivery, including prenatal, antenatal and postnatal care. Hyperglycemia in pregnancy (HIP) is the most common medical condition encountered during pregnancy. There is little guidance for primary care physicians for providing delivery of optimal perinatal care while minimizing the risk of COVID-19 infection in pregnant women. This review aims to describe pragmatic modifications in the screening, detection and management of HIP during the COVID- 19 pandemic. In this review, articles published up to June 2021 were searched on multiple databases, including PubMed, Medline, EMBASE and ScienceDirect. Direct online searches were conducted to identify national and international guidelines. Search criteria included terms to extract articles describing HIP with and/or without COVID-19 between 1st March 2020 and 15th June 2021. Fasting plasma glucose, glycosylated hemoglobin (HbA1c) and random plasma glucose could be alternative screening strategies for gestational diabetes mellitus screening (at 24–28 weeks of gestation), instead of the traditional 2 h oral glucose tolerance test. The use of telemedicine for the management of HIP is recommended. Hospital visits should be scheduled to coincide with obstetric and ultrasound visits. COVID-19 infected pregnant women with HIP need enhanced maternal and fetal vigilance, optimal diabetes care and psychological support in addition to supportive measures. This article presents pragmatic options and approaches for primary care physicians, diabetes care providers and obstetricians for GDM screening, diagnosis and management during the pandemic, to be used in conjunction with routine antenatal care.
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