Pregnancy complicated by clinical diabetes mellitus. A study of 600 pregnancies.

In a consecutive series of 600 pregnancies (618 infants) in 300 clinically diabetic patients, treated in Dublin, Ireland, the maternal mortality was 0 and the loss of viable infants was 9.5%. Therapeutic abortion and sterilization were not practiced. The cesarean section rate was 23%. The major causes of perinatal loss were hyaline membrane disease and congenital malformations. Recent routine estimation of the L/S ratio in amniotic fluid led to a reduced incidence of respiratory distress syndrome and a consequent improvement in perinatal mortality. At a very early stage in pregnancy diabetic patients should be referred to a center in which physician, obstetrician, nurse, and pediatrician operate as a team. Strict control of diabetes is essential.

Pregnancy in the diabetic patient: timing and mode of delivery.

The clinical outcome of 141 consecutive diabetic pregnancies managed in the National Maternity Hospital between January 1, 1979, and October 31, 1982, is described. Patients with gestational diabetes were excluded. There were 12 spontaneous abortions, and the perinatal mortality in 129 viable pregnancies was 31/1000. The malformation rate was 6.4%. Significant perinatal morbidity occurred in 20% of infants. The incidence of cesarean section was 20%. Spontaneous labor after 38 weeks occurred in 30% because there was a deliberate policy to allow all uncomplicated pregnancies to continue to term. This policy had benefits for the infant as well as the mother because there was a notable reduction in neonatal morbidity. Possible explanations of high cesarean section rates in other centers are discussed.

Hidradenitis suppurativa. Glucose tolerance, clinical, microbiologic, and immunologic features and HLA frequencies in 27 patients.

Glucose tolerance, lymphocyte populations, and HLA types were studied in 27 patients with untreated hidradenitis suppurativa; 18 of these patients had a negative history for acne vulgaris. Six patients (22%) had an increased incidence of impaired glucose tolerance. We failed to confirm a previous report of high incidence of flat glucose tolerance curves. The frequency of HLA-A and HLA-B antigen loci and the median values of peripheral blood T lymphocytes were similar to the control population. However, seven patients with moderate or severe clinical disease had a marked reduction in T lymphocytes and these patients had an increased frequency of the HLA antigens, A1 and B8. These results suggest that T lymphocytes may play a role in the pathogenesis of hidradenitis suppurativa and that HLA-A1 and HLA-B8 may predispose the patient to more severe disease, but further research is necessary to clarify this.

The effect of pregnancy on the natural course of diabetic retinopathy.

To determine the influence of pregnancy on the retinas of insulin-dependent diabetics, we assessed 53 diabetic women by retinal photography every six weeks throughout pregnancy and for six months post partum. Thirty-nine nonpregnant insulin-dependent diabetics of childbearing age served as controls. Of the 39 controls, 18 (46.2%) had retinopathy. Of the 53 pregnant women, 33 (62%) had retinopathy at the first examination and eight others (15%) developed it as pregnancy advanced, significantly increasing the prevalence of retinopathy during pregnancy to 77.4%. Progressive changes occurred as pregnancy advanced; microaneurysms moderately increased, hemorrhages appeared in 30 (56.6%), and soft exudates in 15 (28.3%). Four patients (7.5%) had neovascularization, one for the first time. The condition of all four deteriorated during pregnancy. Six months after delivery the background changes had regressed to control levels. Neovascularization showed some regression. Duration of disease was related to the development and progression of retinopathy; every pregnant patient who had had diabetes for ten years had retinopathy. Retinal hemorrhages or neovascularization were associated with increased infant morbidity. Hemorrhages and exudates behaved independently and were associated with different risk factors, but increased insulin requirements and polyhydramnios were important risk factors in the development of retinal hemorrhages. Low fasting blood glucose levels late in pregnancy were significantly associated with soft exudates.

Retinopathy and retinal function in insulin-dependent diabetes mellitus.

Sixty-six insulin-dependent diabetic patients with normal visual acuity were studied (132 eyes). The mean age was 27.7 years with a mean duration of diabetes mellitus of 8.7 years. Their mean electro-oculogram ratio, Arden grating and Munsell-Farnsworth scores were markedly abnormal (p much less than 0.00001). Background retinopathy was present in 53 eyes (40.2%), abnormal Arden grating scores (greater than 82) in 70 eyes (53%), abnormal Farnsworth-Munsell 100-hue score (greater than 100) in 88 eyes (56.7%), and 29 eyes (22%) had an electro-oculogram ratio less than 160. These abnormalities of retinal function did not correlate with retinopathy and were not secondary to it. Smoking caused a significant deterioration in contrast sensitivity.

An assessment of a microcolumn chromatographic method for the measurement of haemoglobin A1.

A microcolumn method for the measurement of haemoglobin A1 (Hb A1) was assessed . The between assay coefficient of variation was less than 4%. Factors influencing the assay are discussed. Fluoride oxalated blood was found to be unsuitable for Hb A1 assay. Hb A1 in whole heparinised blood was found to be stable for nine days at 4 degrees C and for longer if buffered dextrose was added to the sample. The possibility of artefactual lowering of the Hb A1 value by the selective loss of older red cells was investigated.

The immunogenic properties of a highly purified insulin preparation.

Twenty patients who had never previously received insulin were treated with a highly purified preparation (NPH LEO in R.I. quality). Insulin antibody estimations were performed over a 14 to 19 month period. Detectable amounts of antibodies were formed by 18 of the 20 patients. The levels were lower than those found in patients on conventional insulins but moderate levels were found in 7 patients. No correlation was found between the development of antibodies and changes in insulin requirement.

Hypothyroidism and coeliac disease-A family study.

A family of ten children is described. Five were hypothyroid and two had coeliac disease, both disorders coexisting in one child. IgA deficiency was present in the mother and one child.

Histocompatibility antigens and haemochromatosis in Ireland.

Twenty patients with primary idiopathic haemochromatosis were tissue typed. HLA-A3 and B7 were increased in frequency. The significance of these findings in relation to other studies is assessed.

A review of thyroid disease in pregnancy.

Goitre is common and alterations in biochemical indices of thyroid function are invariable during pregnancy , but thyroid disease, of which hyperthyroidism is the most frequent (0,05% of 72,257 pregnancies at three Dublin Maternity Hospitals, 1979-81) is rare. Good results in terms of perinatal loss (4/112, 3.57%) has been achieved by one of us (MID) in 109 pregnancies using antithyroid drugs alone. Neonatal thyrotoxicosis occurs in one to two percent of babies born to mothers with thyroid disease. The condition is usually transient but a prolonged course may occur in up to 20 percent. Successful pregnancy is possible despite maternal hypothyroidism; three such pregnancies have been managed by one of us (MID). Clinical hyperthyroidism due to trophoblastic disease is very rare and is cured by evacuation of molar tissue. The course of thyroid cancer is not affected by pregnancy.