Diabetes in pregnancy

B efore the advent of insulin therapy, few patients with diabetes who were within the group that is now called "type I" (or insulin-dependent) became pregnant. Of those who did, about 30010 died and the rate of fetal mortality was around 50%.' By 1955, Sir John Peel, who wrote from the British home of care for pregnant patients with diabetes King's College Hospital, London had found a reduction in the rate of fetal loss to "only" 25%;2 similar figures were published from my own hospital in 1958. Although the problem of gestational diabetes was recognized in 1903 "diabetes has been known to set in during pregnancy and disappear spontaneously after delivery" very few hospitals in this country had adopted a systematic approach to the detection of this problem, even by 1976. In this issueof the Journal (page 187),The Royal Women's Hospital Group from Melbourne discusses 15 years of experience with diabetes mellitus in pregnant patients. Very appropriately, the authors include a physician who is well experienced in diabetic care in pregnant women, an obstetrician with a commitment to these patients and a neonatal paediatrician. Between 1970 and 1985, they note a perinatal mortality of 7.5% in 399 women with pre-existing diabetes. In the quinquennia within that period the mortality rate has fallen from 12.2% to 3.9%. These are very good results but the mortality rate is still substantially higher than that in women without diabetes. Two questions need to be asked and answered: "How have these good results been achieved?"; and "Why is there a stubborn residue of excess perinatal deaths?" . The answers to the first question lie in a team approach, the increased awareness of the need for excellence of maternal diabetic control and the advent of case finding and screeningin the normal obstetric population. The answer to the second question lieslargely in the excess of lethal congenital malformations in children of women with diabetes. This excess of deaths defies reduction in most centres, but the problem should be resolved in the longer term. The "team approach" was first proposed by R.D. Lawrence who was a physician at King's College Hospital in London" and himself suffered from diabetes; this approach is now used in all centres of excellence in Australia" and elsewhere.' At a minimum, the "team" should consist of an obstetrician with a special interest in diabetes, a physician with a commitment to the care of pregnant patients with diabetes and a similarly committed perinatal or neonatal physician. The team should also involve nurse educators, dieticians, 24-hour laboratory services, anaesthetists, ophthalmologists and renal physicians. This combination will be found rarely outside a teaching hospital.