Screening of all pregnant women for gestational diabetes is advocated by consultant endocrinologist Prof Fidelma Dunne, a nationally and internationally recognised diabetes specialist.
The current system of selective screening, done on the basis of a set of risk factors, means that “lots of cases” are being missed, she contends, leading to poorer outcomes for mothers and/or babies.
A study conducted over a decade ago in the west, where she is a professor of medicine in NUI Galway, found a prevalence rate of gestational diabetes of 12.4 per cent when all women were screened – a rate considerably higher than previously thought. Researchers calculated that they would have missed 137 out of the 550 women who did have gestational diabetes if they had applied selective screening based on Irish criteria at the time.
The screening test is very simple, she says, and in more than 50 per cent of cases, a low-cost intervention in terms of diet and exercise has been shown to have very important consequences for the outcome of the pregnancy.
This is also not just about pregnancy because gestational diabetes “identifies an at-risk woman and an at-risk baby for their future health”.
Within about 10 years of having GD, 44 per cent of the women will have developed prediabetes or type two diabetes.
“So if we can identify this high risk population at the time of pregnancy, in addition to treating the condition for pregnancy we can also put in place, perhaps, a community intervention programme to try and reduce the prevalence of ongoing prediabetes and diabetes in that population.”
Babies of mothers with GD also have a higher chance of obesity and type 2 diabetes. But if you can take the glucose-stress out of the baby’s system while in the womb, she explains, that can benefit them long term too.
The NUIG department of health economics was able to show universal screening would prove cost-effective in the long term but whether it is deemed “affordable” by government is another matter, she acknowledges. Barriers to universal screening include not only the cost but also the fact that currently the testing is done in already overcrowded hospitals, which would struggle to cope with the additional workload.
“If we could move the screening from the hospital system to the community system,” she says, there would be less barriers. It would also help if there was a change to the current practice of moving all women diagnosed with GD away from low-risk obstetric management by midwives in the community.
That is a decision made by obstetrics, she says, “and one of the drawbacks of the system currently”. She suggests women whose condition can be treated by diet only could be looked after by the usual obstetric consultant supporting midwifery care “if there was a virtual way to review the sugars”.
The NMH has achieved such a system of virtual review “because the number of midwives and dietitians that they have to support the [diabetes] service is far in excess of what any other hospital around the country has”, she observes.
“If we could have that level of staffing pro rata in other hospitals, we could also do it but we don’t. Hopefully that may change.”
Medical cards
Another change she would like to see, and which Diabetes Ireland lobbied for in its pre-Budget submission, is restoration of financial supports under the long-term illness scheme to women with gestational diabetes. Women with this condition must test their blood multiple times a day and the cost of the test strips was covered by the scheme until 2013.
Only about 40 per cent of affected women have medical cards and that leaves the rest having to pay at least €25 a week for a supply of these strips, usually over 12 weeks.
“I don’t think it is right to penalise this group of women who have this condition by not giving them the resources by which to monitor what is happening with their sugars.”
It is very hard for medical and nursing teams to make decisions about escalating treatment in the absence of such daily readings.
Meanwhile, there is no evidence yet that an apparent 33 per cent increase in the prevalence rate of GD in the UK since the start of the pandemic, based on one large-scale study there, is being replicated here. What’s being suggested is that lack of exercise and more eating at home during lockdown increased the prevalence in the UK.
However, in addition to gestational diabetes, that study may have been picking up some stress-related hyperglycaemia, Dunne says, caused by living during a pandemic. There doesn’t seem to be any pathological link between the Covid-19 virus and development of GD.
Read: Welcome innovation for women with gestational diabetes
