1. Cook Island Presentation PSRH Conference Samoa 12-07-13 Dr. May

2. Comprises of 15 islands spread over 2.2 million square kilometers) of ocean Consists of two main groups Northern Southern The total resident  17,794. Females  8979 Reproductive age  3655 (age 15 to 49 years). Obese-  65.7% of female population Diabetes  21.0% (The STEP Survey – 2009)

3. The problem – burden of diabetes in Cook Islands It is likely that the incidence of GDM in the Cook Islands is rising due to increase in obesity & diabetes amongst the general population

4. The Evaluation of Gestational Diabetes Mellitus Screening and Management in the Cook Islands Dr. May Aung, Dr. M. Sowter. Dr. A. Herman. Dr. T. Kenealy

5. CountryScreening testConfirmation test (75g OGTT)Year/reference 50g OGC 1 hFasting75g OGTT 2h Cook Islands≥7.8≥5.2≥8 Cook Islands GDM guideline(2009) New Zealand≥7.8≥5.5≥9 National GDM technical Working Party (1992) 17 Australia≥7.8≥5.5≥8 ADS Position statement (1991) 15 WHO Not recommended ≥7≥7.8WHO(1999) 7 IDAPSG Not recommended ≥5.1≥8.5 IDAPSG(2008) 13,1 6

6. GDM Screening programme in Cook Islands Universal screening for GDM (Jan 2009) Current approach 2 step method non-fasting 50g glucose challenge test (GCT) at 24 -28 weeks gestation. If their 1h glucose concentration is ≥ 7.8mmol/L-  offered a diagnostic 75g oral glucose tolerance test (OGTT per the WHO protocol for the impaired glucose tolerance outside of pregnancy GDM is diagnosed if the fasting sugar glucose is ≥ 5.2 mmol/L and/ or the 2 hour glucose concentration is ≥ 8mmol/L as per Australian criteria.

7. Literature review Mainly searched on Medline Burden of GDM Currently used screening methods and outcomes in both Pacific and other populations Maternal and perinatal outcomes.

8. Proposed Methodology A review of the published literature on the burden of GDM among Pacific women, screening criteria commonly used, and maternal and perinatal outcomes. Conduct of a retrospective population-based cross sectional survey of all registered deliveries at Rarotonga Hospital, Cook Islands, for the years January 2009 to December 2012, to describe the prevalence of GDM and IGT, management of GDM, and perinatal/postnatal outcomes. Comparative study of the use of the Cook Islands GDM screening criteria to those used in New Zealand and internationally (IDADSG) in determining the prevalence of GDM in the Cook Islands. Based on the above, determine whether the introduction of an enhanced GDM screening programme for the Cook Islands is required.

9. Data Collection Collected retrospectively from the patient health information system used in the Cook Islands, Medtech 32, a proprietary patient management system www.medtech.co.nzwww.medtech.co.nz Allow us to create templates to capture data required Obstetric registers Patient notes/ discharge letters.

10. Information collected Age Gravida (number of pregnancy) Parity (number of live births} Family history of diabetes (first degree relatives) Past obstetric history Birth weight > 4 kg of previous deliveries Gestation at the first prenatal booking visit Body mass index at the first prenatal booking visit Smoking status

11. Information collected Gestation at the time of Oral glucose Challenge (OGC) Test with 50g. Outcome of the OGC test Oral glucose tolerance test conducted and result if done (75g) Blood pressure at 28 weeks of pregnancy. Mode of delivery of index pregnancy Birth weight of index pregnancy Admission to NICU. (indication)

12. Data Analysis Non identifying data extracted from Medtech templates Exported to Excel 2010 and STSTA version 12 (Data analysis will be done by Prof: Tim Keanely)

13. Antenatal Number and proportion (%) of antenatal women who are screened for GDM between 24-28 weeks gestation as per current Cook Islands protocol Number and proportion (%) of antenatal women who screen positive for GDM according to the current Cook Island criteria Number and proportion (%) of antenatal women who are diagnosed with GDM according to the current Cook Islands GDM criteria have timely treatment and good control?

14. Intra partum Number and proportion (%) of antenatal women (diagnosed with GDM, IGT, or normal glucose tolerance) develop complications in pregnancy and labour, these complications being known to be associated with GDM? Number and proportion (%) describing birth characteristics (birth weight, glycaemic status) of babies born to women with either GDM, IGT or normal glucose tolerance?

15. Postnatal Number and proportion (%) of women diagnosed antenatally with GDM have a positive OGTT at 6 weeks postnatal Number and proportion (%) of women diagnosed antenatally with GDM, and have a positive OGTT at 6 weeks post natal, who are referred to the appropriate clinic for ongoing diabetes care

16. Limitations & advantages Small sample size (646 out of 866) Exclusion criteria Incomplete data Known type 2 diabetes Repeated pregnancies during this time overseas Strength– represents 96% of birth in country

17. Ethics Retrospective cross sectional study collecting already existing data Does not involve interviews or questionnaire of human participants Chart number used to protect the identity of people Letter of authorization to collect and use data accordingly received from DHH

18. Data storage All data used in this study is stored in excel format together with a data dictionary+ in the OBGYN clinic computer for future reference.

19. Submission According to timeline, proposal was submitted on the end of May 2013 to :-- The MOH Cook Islands research Committee National Research Committee.

22. Thank You