Coronavirus disease 2019 pandemic practice changes: more harm than good?

In response to the coronavirus disease 2019 (COVID‐19) pandemic, sweeping changes were made to obstetric care. Many practices rapidly converted to telehealth visits or drive‐through obstetric services (Turrentine et al. Obstet Gynecol 2020;136:29–32). Others modified outpatient care practices such as reducing the number of ultrasounds or antenatal surveillance visits. In the manuscript by van‐de‐l’Isle and colleagues, the authors evaluated whether a change to gestational diabetes (GDM) screening guidelines suggested by the Royal College of Obstetricians and Gynaecologists (RCOG) during the COVID‐19 pandemic changed the proportion of pregnant women found to have GDM (van‐de‐l’Isle et al., BJOG 2021;128:917–920).

Overall, the proportion of women diagnosed with GDM decreased fairly dramatically during this time period, from 7.7 to 4.2%. It is noteworthy that women who tested negative for GDM based on RCOG COVID‐19 guidelines were later offered the standard 2‐hour 75‐g glucose tolerance test; 20% of them were then diagnosed with GDM, raising concerns that using the pandemic RCOG guidelines, women with GDM (based on standard testing) were not being diagnosed or treated. Although the authors found a reduction in the proportion of women diagnosed with GDM, it is difficult to solely attribute this directly to a change in the testing algorithm. As noted by the authors, many simultaneous changes occurred in level of activity and dietary changes that may have influenced the rate of GDM. However, the findings lend credence to the position of RCOG to revert back to standard screening processes when possible [RCOG, Guidance for Maternal Medicine Services in the Evolving Coronavirus (COVID‐19) Pandemic, https://www.rcog.org.uk/globalassets/documents/guidelines/2020‐07‐10‐guidance‐for‐maternal‐medicine.pdf].

This work is important and brings to the attention of the obstetric community the importance of evaluating changes to practice on an ongoing basis. Decisions about further modifications should be based on many factors including local prevalence of COVID‐19 infection and hospital resources (Miller et al., Obstet Gynecol 2020;136:232–4). Individual considerations are also valuable, with risk stratification to delineate the importance of specific testing for each person as the risks and benefits will be variable based on existing comorbidities and access to care.

Of course, there is also the broader question of whether this decrease in detection of GDM resulted in increased maternal or neonatal morbidity and mortality. This question cannot be answered by this particular study as the sample size was insufficient to detect rare events. However, the question remains clinically important and is worthy of further investigation. Such a study is in progress through the Eunice Kennedy Shriver National Institutes of Child Health and Human Development Maternal–Fetal Medicine Units Network (ClinicalTrials.gov Identifier NCT04519502).

In short, the COVID‐19 pandemic is a large natural experiment that has changed the way we deliver obstetric care across the globe. Investigators should be encouraged to evaluate the effect of these changes on maternal and neonatal outcomes. Some changes may be beneficial beyond the period of this pandemic. Other changes may cause harm and will need to be abandoned as evidence emerges to further guide our practice now and in the event of future healthcare crises.

Disclosure of interests

Dr Metz is the Principal Investigator for the Utah Center of the Eunice Kennedy Shriver NICHD Maternal–Fetal Medicine Units Network. She is the Study Chair for the MFMU COVID study. Dr Metz reports grants from NICHD, during the conduct of the study; grants from Pfizer, grants from GestVision, grants from Novavax, other from UpToDate, outside the submitted work. A completed disclosure of interests form is available to view online as supporting information.

Supporting information

Supplementary Material