PREGNANCY IN DIABETIC WOMEN: An Analysis of a Series

IN the modern treatment of diabetes mellitus with insulin the aim of the physician is to allow the diabetic woman to lead a normal life which includes the bearing of children. Before 1923 amenorrhoea and infertility were common in diabetic women, and pregnancy was rare and often fatal both to mother and baby, but, since the control of the disease with insulin, it is possible that otherwise healthy diabetic women are as fertile as non-diabetic women. However, the problem of determining the most effective management of the diabetic pregnancy is difficult because the series reported by most centres have necessarily been small, diabetes mellitus being a relatively infrequent disease in the younger age groups. Josh’s (1946) figures for America show that about 1 person in 1,OOO in the childbearing age is diabetic. The incidence of pregnancy associated with diabetes mellitus after 1923 is variously reported. Gilbert and Dunlop (1949) quoted 70 diabetic pregnancies in 20,438 deliveries, approximately 1 in 292. Sheumack (1949), in Sydney, reported 45 viable pregnancies in 38,611 deliveries, or 1 in 858. Peel and Oakley (1949) noted an incidence at King’s College Hospital of 1 in 50. The figures vary according to the presence or otherwise of a diabetic clinic in the hospital, and the size of the clinic. At St. Thomas’s Hospital, London, where 7,680 deliveries have occurred in the last ten years, there have been 30 viable pregnancies in diabetic women, an incidence of 1 in 256. This figure, of course, does not indicate the fertility of diabetic women as a group. It was considered of interest to examine a series of cases where the diabetes mellitus had been treated by the “free diet” method, to determine if this had any apparent effect on the maternal or foetal mortality or on the incidence of toxaemia in pregnancy. Unfortunately this series is not a large one from a statistical point of view. It comprises 51 pregnancies reaching viable age since 1940, in 29 women with diabetes mellitus, who attended the diabetic clinic at St. Thomas’s Hospital regularly and who all, with one exception, were known to suffer from diabetes before the pregnancy began. Each patient was supervised at the antenatal clinic as soon as pregnancy was diagnosed, usually before the 12th week, following which the women attended both the diabetic and antenatal clinics regularly at least every two weeks, and more often if necessary. The management of pregnancy, labour and puerperium was conducted by a team consisting of an obstetrician, a physician and later a paediatrician. All cases required insulin throughout pregnancy or in the 2nd or 3rd trimesters and this was given either as soluble insulin or as one of the long acting preparations found to be suitable for the individual patient. All patients were changed to soluble insulin at the time of delivery or in the event of any surgical procedure involving a general anaesthetic. The composition of diet was largely left to appetite and except in cases of obesity no restriction was placed on the patients’ caloric intake or on the form in which carbohydrate foods were taken. It was found that with this method the day-to-day caloric value of the diet tended to remain fairly constant (Goadby, 1950). The importance of regular meal hours was stressed.