Dr Emma Jamieson will be speaking at our upcoming symposium for health professionals, Screening for GDM – are we getting it right?  She talks to ZOE DELEUIL about her involvement with the ORCHID Study, which aims to improve gestational diabetes screening and management in rural and remote WA.   

Q: One of the ORCHID Study’s aims is to simplify screening for high blood glucose (hyperglycaemia) in pregnancy. What are some of the challenges of the current screening for women?

A: The oral glucose tolerance test (OGTT) is a tricky test. There are so many competing interests for a woman’s time. For an OGTT, women must fast overnight, then sit and wait in the clinic for two hours. They may have to organise childcare or time off work. A quicker test, or an at-home one, would be better.

Our original audit showed that half women in rural and remote settings were not getting the test, and as a result we are likely missing their gestational diabetes.  

Q: The first phase of your research shows that 62% of women with gestational diabetes in rural and remote Western Australia may have been undiagnosed. Were you expecting that number?

A: When we began the study, we were looking at alternate tests for women who had declined the OGTT. But when we looked at women who had done the test, the numbers coming back with gestational diabetes were lower than expected. That’s when we realised there was an issue in the handling of samples.

In our study of women in rural and remote areas, the median time of arrival at the lab was five hours, and we know that blood samples are unstable for four hours. We estimated that we were missing almost two in every three women with GDM.

Q: What are the risks for women whose GDM diagnosis is missed?

A: We looked at 470 women and their birth outcomes and found that one in five women who should have had a GDM diagnosis delivered a large baby, which potentially could have been avoided. So that’s the immediate risk for those women.

Then there’s the long-term impact. We can prevent or delay type 2 diabetes in women who have had GDM, but if they aren’t identified, they miss out on that support after pregnancy.  

Q: The second phase of your research looks at an alternative to the OGTT. Can you tell us more about this?

A: We found that, particularly for Aboriginal women, an HbA1c test early in pregnancy could predict a GDM diagnosis later on.  

We think these women likely have prediabetes at conception, which is when your blood glucose levels are high, but not high enough to be diagnosed with type 2 diabetes.  

Pregnancy hormones then stop the insulin from working as well, which pushes blood glucose levels even higher. So, we’re thinking we can identify women within the first trimester. 

A GDM diagnosis can come as a shock to a young, otherwise healthy woman. This is a time when they want to focus on being a new mum, but they have this additional burden of having to self-manage their GDM. The earlier we can start working with women to empower them, the better.

If we can pick it up earlier, we have more time to educate around diet and lifestyle and give women time to come to terms with their diagnosis. First trimester is also an important point in the development of the baby. Around 8-12 weeks the baby starts making their own insulin cells and can be impacted by mum’s blood glucose levels.

Q: You’re working on developing culturally appropriate management strategies for Aboriginal women with hyperglycaemia detected early in pregnancy. What might these look like?

A: We’ve spoken to almost 50 women with GDM, their family members and healthcare providers about their experiences, and we’ve held community workshops in the Kimberley and the Southwest to talk to Elders and community members about how to make a family-centred program. 

From this, we’ve come up with three main strategies. The first recommendation is the need for an Aboriginal Health Navigator. They don’t necessarily have to have clinical skills but are there to guide the woman and her family through the process, meeting with the diabetes educator and dietitian and liaising with the hospital and being there for all the additional appointments that come with a GDM diagnosis.

The second is for greater CGM use for monitoring blood glucose levels during pregnancy. Many women talked about the pain of doing fingerpricks and the stress of going out on Country and needing to remember a kit. Women are very on board with using a CGM instead to reduce that stress.

The third is for continuity of care. We found that woman with GDM valued midwifery care from their Aboriginal Community Controlled Health Services. But often they found they’d get to the six-week baby check, and then everything became all about the baby. They would be discharged back to the GP and the care really dropped away.

We’d like to see the Aboriginal Health Navigator follow up with women for six or even twelve months after delivery. A lot of women had done either the follow-up OGTT or HbA1c after pregnancy, but they also wanted support to maintain those healthy changes they’d adopted during pregnancy, which is key for avoiding progression to type 2 diabetes. It’s a really important time for women.

Q: What difference does it make to women’s future health if they are offered the right support during pregnancy and beyond? 

A: It makes a huge difference. We also want there to be support for the baby’s father and wider family and incorporate point-of-care HbA1c testing for the father and other family members, because any lifestyle changes are a team effort.

We also want to put more support into breastfeeding and the positive impact it can have. Women we spoke to were aware of the benefits in general, but didn’t know that it can reduce the likelihood of GDM in subsequent pregnancies and type 2 diabetes.

Women who have diabetes, or have had GDM, may need more support to establish breastfeeding.

Q: What do you find rewarding about research in this area?

A: I love working rurally and remotely with people because they are so passionate and engaged about improving health in their communities.

I also love the fact that some of the findings we’ve made since 2014 have already been translated into changes in clinical practice. 

Dr Emma Jamieson is a Future Health Research and Innovation Fund Translational Research Fellow based in the Southwest region. As part of a team of state-wide researchers, clinicians and community members, she conducts collaborative community and health services research to improve health outcomes in rural and remote Australia. The predominant focus of her research is improving outcomes for people with diabetes; her PhD on screening for hyperglycaemia in pregnancy in rural and remote communities has led to implementation of improved screening pathways for pregnant women and a collaboration with the National Harmonisation Glucose Preanalytical Working Party. Prior to her time with RCSWA, her focus was on pancreatic islet biology and transplantation research at St Vincent’s Institute (Melbourne) and Harry Perkins Institute (Perth).