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The pregnant diabetic and her newborn
BOOKS Edited LOUIS
by M.
HELLMAN,
M.D.
AND RALPH
M.
WYNN,
M.D.
Book review The Pregnant Diabetic and Her J. Pedersen. 219 pages, illustrated. 1968, The Williams & Wilkins $11.50.
Newborn. Baltimore, Company.
Several minor errors creep into the book. For example, six lines from the bottom of page 38 there apparently is omitted the phrase “insulintreated” in describing a group of diabetic women; otherwise, the sentence erroneously implies that all diabetic subjects have circulating insulinbinding antibodies. The discussion of aglycosuric diabetes begins on page 182, not page 181 as listed in the table of contents. “Tiazide,” on page 194, is more likely to be recognized as “thiazide” by American readers, as is “lslIinsulin” rather than “rslJ-insulin (page 58) .” One objection that I must express, probably a personal idiosyncrasy, is the extensive use of abbreviations or symbols. It would hardly appear necessary to conserve space in a book this size, by replacing “low birth weight babies” by LBWB, or “big babies” by BB, or to condense a phrase that would probably read “a blood sugar of between 90 and 119 mg. per 100 ml.” by the expression (page 191) “. . . >= 90 < 120. . . .” Furthermore, the reader will find “1.t.” and “sh. t. cases” on page 45, but not learn until page 69 that these stand, respectively, for long-term treatment and short-term treatment. One highly interesting chapter is devoted to the classification of gestational diabetes, and the use of classification in prognostication. The Pedersen system, PBSP (that is, prognostically bad signs in pregnancy), is discussed and compared with the widely used White system. The latter is a classification determined by the nature of the mother’s diabetes before pregnancy has begun. The PBSP system, however, is dynamic, taking into account events occurring during preg-
In The Pregnant Diabetic and Her Newborn, Dr. Jen-gen Pedersen, one of the authorities in the field, has condensed over 20 years of personal research and clinical experience into a slender, balanced, and eminently useful volume. The book contains approximately 195 pages of text and illustrative material and some 22 pages of references. The type is large and readily legible and the lines widely spaced with ample room in the margins for those addicted to privately feuding with authors. Each of the 14 chapters is subdivided into several topics, and the chapter and subtopic headings listed in the table of contents. Within a given chapter a brief introduction is provided, the topic is then developed, and, generally, some concluding remarks or a brief summary is appended. Although the table of contents is detailed, an index is lacking and would have been appreciated by this reader. The volume is based on experience with several hundred diabetic pregnancies, and it integrates with this material a selective, rather than exhaustive, review of the literature. Several comprehensive surveys of the earlier literature are cited, thus giving the reader access to an enormous literature on gestational diabetes. Of the nearly 400 references given by the author, approximately two-thirds were published after 1960. The reference list is studded with many items published as recently as 1966 and, occasionally, 1967. 1142
Volume Number
101 8
nancy (clinical pyelonephritis, severe acidosis, toxemia, or a neglected and unsupervised pregnancy). It appears worthy of wide study and application. Since the White and PBSP systems are complementary, their combined use should, as the author points out, improve “the possibility of predicting the foetal prognosis as compared to the use of either one separately” (page 116). Pedersen devotes approximately 35 pages to a conservative and well-reasoned appraisal of factors that should alert the physician to the presence of diabetes during pregnancy and to screening tests for the disorder. His criteria for selection of the patient with gestational diabetes, based on a 150 minute oral glucose tolerance test after “50 Gm. glucose or more” (no explanation for the qualification, nor guide to the actual amount to be used are given) would probably be accepted by most workers in this field. In one sense this last chapter of the book ought to be the first, for the reader must skip to this chapter in order to evaluate all the chapters dealing with the composition of the author’s series. Perhaps it should be emphasized at this point that tolbutamide tolerance tests have little or no diagnostic value during pregnancy, since virtually all such tests become moderately abnormal (i.e., diabetic) during even normal pregnancies. Medicolegal or medicoeconomic differences between Denmark and the United States will make certain therapeutic procedures discussed by Pedersen of only academic interest. “Eugenic” or “medicoeugenic” therapeutic abortion and sterilization are available in Denmark, where “a pregnancy may be interrupted for eugenic reasons when diabetes is present also in the child’s father . . . or if the couple has already one diabetic child.” Some 15 per cent of therapeutic abortions, and 11 per cent of sterilizations, in the author’s series of such procedures in diabetic women were based on these grounds. While the author clearly voices his dismay at the practice, one may wonder at his preference to “not advise diabetic women to use oral contraceptives because they, probably, may influence the diabetic state with changes similar to those seen in pregnancy” (page 155). Extended hospitalization is used almost routinely by Pedersen, his patients being admitted to the hospital about 8 weeks before the calculated due date. This policy permits close supervision and control of the diabetic state and facilitates early induction of labor (at approximately the thirty-seventh week),
Books
1143
with the intent of delivering a baby weighing 3,500 to 3,950 grams. Despite this approach perinatal mortality in the series 1959 to 1965 averaged 17 per cent. Over fifty per cent of the deaths were due to hyaline membranes or other respiratory causes. Deferring delivery might be expected to improve perinatal survival, as the author implies, provided death in utero can be averted by “tight” control of the diabetic state. Possibly the availability and application of such techniques as rapid estriol determinations and monitoring of the fetal ECG may further improve the odds for the physician (and patient) in this desperate gamble. No explanation is presently available of the changes seen in carbohydrate and fat metahohsm during pregnancy. As Pedersen indicates in a concise and balanced review, the placenta has become the focus of investigative attention, particularly with regard to the recently reported placental lactogen. This substance, which crossreacts immunologically with human growth hormone has been linked inferentially to tht% state of insulin resistance that characterizes both normal and diabetic pregnancies. Although it has been shown that tolbutamide intolerance subsides within 24 hours of delivery and that lipidmobilizing activity is obtainable from the piacenta and is found in the blood of pregnant w’omen, other studies (employing highly purifircl pIacental lactogen) have failed to demonstrate a major effect of this substance on carbohydrate metabolism. Whether the extraction process employed in purifying placental lactogen disrupts or denatures a labile component, whether another substance not yet identified is responsible. or whether other hormonal changes must take place to provide a requisite hormonal milieu are aII questions with incomplete experimental answers. This area will certainly prove to IX one of the more exciting and potentially fruitful areas for investigation during the coming decade. In writing this review I notice that I have used such words as “balanced,” “comer vative,” and “useful.” I should have added the word “enjoyable.” In short, the book is a pleasure to read, for its information as well as its style. It is highly recommended to the internist, the pediatrician, and the obstetrician who are interested in, and deal with, the problem c~f gestational diabetes.
by M.
HELLMAN,
M.D.
AND RALPH
M.
WYNN,
M.D.
Book review The Pregnant Diabetic and Her J. Pedersen. 219 pages, illustrated. 1968, The Williams & Wilkins $11.50.
Newborn. Baltimore, Company.
Several minor errors creep into the book. For example, six lines from the bottom of page 38 there apparently is omitted the phrase “insulintreated” in describing a group of diabetic women; otherwise, the sentence erroneously implies that all diabetic subjects have circulating insulinbinding antibodies. The discussion of aglycosuric diabetes begins on page 182, not page 181 as listed in the table of contents. “Tiazide,” on page 194, is more likely to be recognized as “thiazide” by American readers, as is “lslIinsulin” rather than “rslJ-insulin (page 58) .” One objection that I must express, probably a personal idiosyncrasy, is the extensive use of abbreviations or symbols. It would hardly appear necessary to conserve space in a book this size, by replacing “low birth weight babies” by LBWB, or “big babies” by BB, or to condense a phrase that would probably read “a blood sugar of between 90 and 119 mg. per 100 ml.” by the expression (page 191) “. . . >= 90 < 120. . . .” Furthermore, the reader will find “1.t.” and “sh. t. cases” on page 45, but not learn until page 69 that these stand, respectively, for long-term treatment and short-term treatment. One highly interesting chapter is devoted to the classification of gestational diabetes, and the use of classification in prognostication. The Pedersen system, PBSP (that is, prognostically bad signs in pregnancy), is discussed and compared with the widely used White system. The latter is a classification determined by the nature of the mother’s diabetes before pregnancy has begun. The PBSP system, however, is dynamic, taking into account events occurring during preg-
In The Pregnant Diabetic and Her Newborn, Dr. Jen-gen Pedersen, one of the authorities in the field, has condensed over 20 years of personal research and clinical experience into a slender, balanced, and eminently useful volume. The book contains approximately 195 pages of text and illustrative material and some 22 pages of references. The type is large and readily legible and the lines widely spaced with ample room in the margins for those addicted to privately feuding with authors. Each of the 14 chapters is subdivided into several topics, and the chapter and subtopic headings listed in the table of contents. Within a given chapter a brief introduction is provided, the topic is then developed, and, generally, some concluding remarks or a brief summary is appended. Although the table of contents is detailed, an index is lacking and would have been appreciated by this reader. The volume is based on experience with several hundred diabetic pregnancies, and it integrates with this material a selective, rather than exhaustive, review of the literature. Several comprehensive surveys of the earlier literature are cited, thus giving the reader access to an enormous literature on gestational diabetes. Of the nearly 400 references given by the author, approximately two-thirds were published after 1960. The reference list is studded with many items published as recently as 1966 and, occasionally, 1967. 1142
Volume Number
101 8
nancy (clinical pyelonephritis, severe acidosis, toxemia, or a neglected and unsupervised pregnancy). It appears worthy of wide study and application. Since the White and PBSP systems are complementary, their combined use should, as the author points out, improve “the possibility of predicting the foetal prognosis as compared to the use of either one separately” (page 116). Pedersen devotes approximately 35 pages to a conservative and well-reasoned appraisal of factors that should alert the physician to the presence of diabetes during pregnancy and to screening tests for the disorder. His criteria for selection of the patient with gestational diabetes, based on a 150 minute oral glucose tolerance test after “50 Gm. glucose or more” (no explanation for the qualification, nor guide to the actual amount to be used are given) would probably be accepted by most workers in this field. In one sense this last chapter of the book ought to be the first, for the reader must skip to this chapter in order to evaluate all the chapters dealing with the composition of the author’s series. Perhaps it should be emphasized at this point that tolbutamide tolerance tests have little or no diagnostic value during pregnancy, since virtually all such tests become moderately abnormal (i.e., diabetic) during even normal pregnancies. Medicolegal or medicoeconomic differences between Denmark and the United States will make certain therapeutic procedures discussed by Pedersen of only academic interest. “Eugenic” or “medicoeugenic” therapeutic abortion and sterilization are available in Denmark, where “a pregnancy may be interrupted for eugenic reasons when diabetes is present also in the child’s father . . . or if the couple has already one diabetic child.” Some 15 per cent of therapeutic abortions, and 11 per cent of sterilizations, in the author’s series of such procedures in diabetic women were based on these grounds. While the author clearly voices his dismay at the practice, one may wonder at his preference to “not advise diabetic women to use oral contraceptives because they, probably, may influence the diabetic state with changes similar to those seen in pregnancy” (page 155). Extended hospitalization is used almost routinely by Pedersen, his patients being admitted to the hospital about 8 weeks before the calculated due date. This policy permits close supervision and control of the diabetic state and facilitates early induction of labor (at approximately the thirty-seventh week),
Books
1143
with the intent of delivering a baby weighing 3,500 to 3,950 grams. Despite this approach perinatal mortality in the series 1959 to 1965 averaged 17 per cent. Over fifty per cent of the deaths were due to hyaline membranes or other respiratory causes. Deferring delivery might be expected to improve perinatal survival, as the author implies, provided death in utero can be averted by “tight” control of the diabetic state. Possibly the availability and application of such techniques as rapid estriol determinations and monitoring of the fetal ECG may further improve the odds for the physician (and patient) in this desperate gamble. No explanation is presently available of the changes seen in carbohydrate and fat metahohsm during pregnancy. As Pedersen indicates in a concise and balanced review, the placenta has become the focus of investigative attention, particularly with regard to the recently reported placental lactogen. This substance, which crossreacts immunologically with human growth hormone has been linked inferentially to tht% state of insulin resistance that characterizes both normal and diabetic pregnancies. Although it has been shown that tolbutamide intolerance subsides within 24 hours of delivery and that lipidmobilizing activity is obtainable from the piacenta and is found in the blood of pregnant w’omen, other studies (employing highly purifircl pIacental lactogen) have failed to demonstrate a major effect of this substance on carbohydrate metabolism. Whether the extraction process employed in purifying placental lactogen disrupts or denatures a labile component, whether another substance not yet identified is responsible. or whether other hormonal changes must take place to provide a requisite hormonal milieu are aII questions with incomplete experimental answers. This area will certainly prove to IX one of the more exciting and potentially fruitful areas for investigation during the coming decade. In writing this review I notice that I have used such words as “balanced,” “comer vative,” and “useful.” I should have added the word “enjoyable.” In short, the book is a pleasure to read, for its information as well as its style. It is highly recommended to the internist, the pediatrician, and the obstetrician who are interested in, and deal with, the problem c~f gestational diabetes.