The impact of lockdown on maternal and neonatal morbidity in gestational diabetes mellitus

Abstract

Objective In France, during the 2020 COVID-19 pandemic lockdown, maternal and pregnancy care had to adapt to government rules. Consequently, many institutions provided remote consultations. This study aimed to examine the impact of the lockdown on maternal and fetal morbidity in pregnant women with gestational diabetes mellitus (GDM). Study Design A retrospective single-center study was performed, comparing 2 groups: patients with GDM during the COVID-19 lockdown from March 18, 2020 to May 7, 2020 (lockdown period) and patients with GDM during the same interval in 2019 (prelockdown period). These data were analyzed anonymously, and our database was declared to the French Committee for Computerized Data (CNIL 21/846). All pregnant patients who were followed up for GDM during the 2 periods were included. In the prepandemic period, patients diagnosed with GDM attended a day clinic where they were taught about GDM. During the 2020 lockdown, all consultations were initially remote (via telemedicine). Patients entered their data in myDiabby software (myDiabby Healthcare, Bordeaux, France) following the same protocol. 1 Online demonstrations, educational videos, and remote consultations were made available to patients. Pregnancy, maternal, labor, and neonatal characteristics were recorded and compared between the 2 groups. Results A total of 384 patients were included: 203 in the prelockdown period and 181 in the lockdown period. The 2 groups were similar. Compared with prelockdown, lockdown was associated with more GDM treated with insulin (33% vs 45.9%; odds ratio [OR], 1.58; 95% confidence interval [CI], 1.016–2.444; P=.042), a higher rate of cesarean deliveries (23.2% vs 33%; OR, 1.65; 95% CI, 1.03–2.65; P=.037), and more neonatal macrosomia with birthweights >4000 g (6.9% vs 15.5%; OR, 2.49; 95% CI, 1.23–5.02; P=.010) (Table ). There were no significant differences in other labor morbidities. Patient engagement with remote consultations and glycemic monitoring was not affected by lockdown in this study. Table Comparison of the maternal, labor, and neonatal comorbidities during pregnancy and per partum between the prepandemic (2019) and lockdown period (2020) Comorbidities Prepandemic period (2019)N=203 Lockdown period (2020)N=181 P value P value after adjusted analysis and ORa Maternal morbiditiesb Excessive weight gain 51 (25.4) 44 (24.3) .81 GDM treated with insulin 67 (33.0) 83 (45.9) .010c .04c, OR=1.57 (1.02–2.44) Self-monitoring of blood glucose 174 (88.3) 163 (92.6) .16 Attendance at remote consultations 177 (89.8) 163 (92.6) .35 Hospital admissions 50 (24.6) 37 (20.4) .33 .33  • For unbalanced GDM 5 (2.5) 5 (2.8) 1  • For risk of premature birth 9 (4.4) 3 (1.7) .12 Hypertensive disorders during pregnancy 13 (6.4) 9 (5.0) .55 Labor outcomeb Term at delivery (wk+d) 39+3 (39; 40+4) 39+3 (39; 40+3) .65 Labor induction 70 (34.5) 71 (39.2) .34 .42  • For unbalanced GDM 18 (9.0) 25 (13.9) .13 .14 Instrumental birth 28 (13.8) 27 (14.9) .75 .39 Third- or fourth-degree perineal tears 6 (3.0) 4 (2.2) .75 Cesarean delivery 47 (23.2) 58 (33) .033c .03c, OR=1.65 (1.03–2.65)  • Scheduled cesarean delivery 14 (6.9) 19 (10.6) .20  • Emergency cesarean delivery 33 (16.3) 39 (21.9) .16 .14 Postpartum hemorrhage 29 (14.3) 32 (17.8) .35 .45  • Severe >1L 6 (3.0) 12 (6.6) .089 Neonatal outcomeb Birthweight >4000 g 14 (6.9) 28 (15.5) .008c .01c, OR=2.49 (1.24–5.02) Neonatal arterial pH <7.10 18 (9.0) 24 (13.5) .17 .20 Apgar score <8 2 (1.0) 7 (3.9) .090 NICU admission 7 (3.5) 5 (2.8) .70 Neonatal hypoglycemia 41 (20.5) 24 (13.3) .064 .06 BMI, body mass index; GDM, gestational diabetes mellitus; NICU, neonatal intensive care unit; OR, odds ratio. Tollini. Lockdown impact on morbidity of patients with gestational diabetes mellitus. Am J Obstet Gynecol 2022. a Adjusted analysis of patient characteristics (age, parity, BMI, weight gain) b Results are median (interquartile range) or number (percentage). Between-group comparisons were made using the chi square or Fisher exact test for categorical variables, and the Mann–Whitney U test for continuous variables. P ≤.05 was considered statistically significant c Significant result. Conclusion During the lockdown period, glycemic control was poorer than in the same period the year before. 2 Insulin had to be administered more often in 2020 to restore appropriate glucose levels although the patient engagement rate for remote consultations was not significantly affected by lockdown. It is well known that GDM treated with insulin is responsible for many obstetrical and neonatal complications. 3 Thus, another effect of the lockdown was a higher number of cesarean deliveries, with a 1.6 times higher risk of having a cesarean delivery, and birthweights >4000 g. Poor glycemic control may be responsible for the rise in scheduled and emergency cesarean deliveries, causing more fetal macrosomia and more fetal distress during labor. 4 Lifestyle plays an enormous role in glycemic control; during lockdown, physical activity was reduced, and patient diets and psychological aspects were negatively affected. 5 In conclusion, these results show that in situations of confinement with difficult access to face-to-face consultations (lockdown, imprisonment, disability, etc.), the focus should be on improving the monitoring of glucose levels to have better glycemic control and reduce maternal and neonatal comorbidities in pregnant patients with GDM. The liberal use of insulin may be necessary to achieve optimal outcomes. Telemedicine and apps such as myDiabby cannot entirely replace the healthcare team but are significant assets to have in these situations.