Aim To describe current practices for screening for gestational diabetes mellitus in the Cook Islands and consider the implications of alternative screening strategies. Methods Eligible women had antenatal care from January 2009 to December 2012. A non-fasting 50 g glucose challenge between 24 and 28 weeks gestation (positive if 1-hour glucose =7.8 mmol/L) was followed by a 75 g oral glucose tolerance test (gestational diabetes mellitus diagnosed if fasting glucose =5.2 mmol/L or 2-hour glucose =8.0 mmol/L; pregnancy impaired glucose tolerance if positive screen and negative diagnostic test). Results Uptake of the screening programme rose from 49.0% to 99.6% by the end of the study period. 646 women had a glucose challenge; for 186/646 (28.8%) the challenge was positive; 183 had an oral glucose tolerance test; 89/646 (13.8%) had pregnancy impaired glucose tolerance; 94/646 (13.9%) had gestational diabetes mellitus. Median maternal weight gain was 6 kg (gestational diabetes mellitus) and 10 kg (normal glucose tolerance); caesarean section rates were 25% and 11% respectively; baby birthweights were not significantly different. 59 women with gestational diabetes mellitus had a post-natal glucose tolerance test at their 6-week check and 21 (35.6%) had diabetes confirmed. Conclusion The gestational diabetes mellitus screening programme has a high uptake and current management appears effective in reducing maternal and fetal weight gain. A proposed new screening programme is outlined.