Book Review

Diabetes Mellitus in Pregnancy

N Engl J Med 1997; 336:736March 6, 1997

Article

Diabetes Mellitus in Pregnancy
Second edition. By E. Albert Reece and Donald R. Coustan. 455 pp., illustrated. New York, Churchill Livingstone, 1996. $105. ISBN: 0-443-08979-5

A second edition of any specialized multiauthored textbook is a tribute to both good editing and good publishing. That there is a demand for such work in this field is shown by the existence of a considerable number of small booklets, larger publications of conference colloquium proceedings, reviews of small, specialized sectors, and broader clinical summaries aimed at postgraduate students. Only one other work has gone to a second edition — the monograph by Jorgen Pedersen published in 1967 that set the standard of careful personal observation and defined the field of study for the next three decades. Pedersen's hypothesis has influenced all three components of the medical team involved in caring for pregnant women with diabetes: the obstetrician concerned about the size of the baby; the neonatologist, who has to manage hypoglycemia after delivery; and the internist, who must deal with the challenging fluctuations of maternal blood glucose concentrations during pregnancy. But Pedersen's concept that maternal hyperglycemia begets fetal hyperinsulinism and thus fetal overgrowth, with long-term effects on metabolism in adulthood, has stood the test of time, with modifications by numerous researchers over the years.

This book contains 29 chapters by 42 authors, 10 of whom are obstetricians, 10 pediatricians, and 11 diabetologists, with important further contributions from epidemiologists, basic scientists, nurse specialists, and dietitians. The main aim of the book is to provide a comprehensive overview of the information available on the pathophysiology of coexisting diabetes and pregnancy and to describe appropriate approaches to the management of various aspects of this multifaceted problem. The important challenge is for each specialist to be stimulated to read the others' chapters. In the days of the generalist family physician, the supervision of childbirth was the bedrock of successful family practice; that type of individualized, multifaceted clinical practice no longer exists, but to be part of a team with the same object is the next best thing. There is no other disease in which the fields of obstetrics, neonatology, and internal medicine are so closely intertwined with basic scientific and epidemiologic concepts and in which medical and nursing interactions at numerous points can have such important effects on the outcome.

The concept of insulin treatment for a woman with gestational diabetes to prevent fetal macrosomia is well reviewed by Coustan. The obstetrical complications encountered in diabetic pregnant women, including preeclampsia and the need for operative delivery, and the associated effects of long-term degenerative medical complications in the mother — chiefly retinopathy and nephropathy — are also discussed in detail. There is an authoritative discussion of the timing, mode, and management of delivery and of neonatal outcome and care. The old dualistic question of whether the effect of pregnancy on the diabetic state is more important than the effect of diabetes on the pregnancy is covered in pathophysiologic terms and in a number of chapters on screening for gestational diabetes, dietary management, exercise, and the biochemical and biophysical assessment of the fetus. Insulin treatment of women with established diabetes is discussed according to North American concepts by Gabbe, an obstetrician with special knowledge in this field. His approach differs from most European approaches in the use of twice-daily mixtures of short- and intermediate-acting insulins rather than a basal–bolus insulin regimen a few times daily. The problems of tight control of diabetes before pregnancy and in the first trimester are discussed by Steel in relation to preconception counseling and contraception.

The long-term epidemiologic effects of hyperglycemia in pregnancy affect both mother and child. The experience of Bennett and Pettitt, who have followed Pima Indian infants into adulthood, and of O'Sullivan in Boston, who has followed diabetic mothers for 25 years, is covered by up-to-date reviews. The possibility of ending the vicious circle in which maternal hyperglycemia affects the next generation through preventive intervention from an environmental rather than a genetic aspect is discussed, although no reference is made to the work of Barker on the relation between the size of infants at birth and the risk of subsequent diabetes. The considerable differences between countries in the prevalence of diabetes and gestational diabetes are discussed by Metzger and Cho.

There are still problems in this field with respect to definitions, screening protocols, outcome measures, prevention, the education of patients and staff members, and the delivery of health care. The second edition of Diabetes Mellitus in Pregnancy reflects the state of the art and will be welcomed both as a reference source and as a practical manual. The sad and gloomy recollections of the late Dr. Priscilla White, who spent virtually her entire career in Boston caring for pregnant women with diabetes, indicate how far the research has come in the past half century. This book is a critical and authoritative signpost to the future.

David R. Hadden, M.D.
Royal Victoria Hospital, Belfast BT12 6BA, United Kingdom