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Notes: Summary. We report five patients with phaeochromocytoma associated with pregnancy and review the 42 other cases reported in the literature from 1980 to 1987. The overall maternal mortality was 17% and the fetal loss 26%; antenatal diagnosis of phaeochromocytoma reduced the maternal mortality to zero and the fetal loss to 15%, but was made in only 53% of the patients. Although phaeochromocytoma is rare, a high index of clinical suspicion must be maintained and all those at risk investigated if earlier diagnosis and improved outcome are to be achieved. Once the diagnosis is confirmed, alpha-blockade is essential and beta-blockade may be required. CT scan or magnetic resonance imaging may be used to localize the tumour during the antenatal period. In the first and second trimesters, tumour resection has a good fetal outcome; in later pregnancy, delivery by elective caesarean section followed by tumour resection is recommended.

Notes: Summary. A retrospective population study in Northern Ireland examined the benefits of centralized care in insulin-dependent diabetic pregnancies. In the 5 years 1979–1983, there were 139 250 deliveries in Northern Ireland and of these 221 pregnancies occurred in 187 insulin-dependent diabetic patients; 100 were managed entirely in peripheral maternity units, 61 were referred from a peripheral unit to the Royal Maternity Hospital, Belfast and 60 were managed entirely in this central referral hospital. The patients referred from the periphery had the worst past obstetric history with a combined perinatal mortality rate of 200 per 1000. During the study period the perinatal mortality rate was 107 for the referred pregnancies, 33 for those managed entirely in the peripheral units and 18 for those managed at the Royal Maternity Hospital. If those pregnancies terminated for fetal abnormality, and deaths beyond the perinatal period are included, the figures for total fetal loss were 15.5%, 5.5% and 7.1% respectively. Overall the major congenital malformation rate was 7.5%, and for the respective groups 6.5%, 3.0% and 13.0%. For the general population during the same period the perinatal mortality rate was 1.4% and the major congenital malformation rate was 2.5%. Thus it is suggested that only peripheral hospitals which can offer combined antenatal/endocrine care and with a neonatal intensive care unit should undertake the management of the pregnant diabetic.

Notes: Abstract The art of obstetrics is not a subject which is often discussed in the pages ofDiabetologia. However, as the care of the diabetic mother and her offspring is rightly an interdisciplinary responsibility between obstetrician, diabetologist and neonatologist, it is important that each has s. close understanding of the various problems. Dr. M.I. Drury (Dublin), speaking as an internist, raises a question on the optimum time and method of delivery of the baby; this has more than purely obstetrical implications. Drs. L. Mølsted-Pedersen (Copenhagen) and C. Kühl (Copenhagen and Klampenborg), obstetrician and internist from the longest-established joint obstetric/diabetic service in the world, present a Scandinavian view on the management of regnancy. Both centres have distinguished records in the management of diabetic pregnancy. The different viewpoints in Denmark and in Ireland are clear — in Copenhagen, therapeutic abortion is practiced in a pregnancy at risk of severe congenital malformation; in Dublin it is not. Dr. Drury quotes a perinatal loss of 13 of 285 pregnancies (4.5%) in the past 5 years, but does not include the recognised spontaneous abortions which, on his overall figures, are about 10% of conceptions. Dr. Molsted-Pedersen reports a perinatal loss of 3 of 201 infants (1.5%), excluding 17 spontaneous and 9 induced abortions. If these 9 aborted pregnancies, which were performed due to a risk of severe congenital malformation, were included as fatalities, the Copenhagen figure would be 12 of 210 (5.5%). Of course, we do not know if all those 9 fetuses were affected. The spontaneous abortion rate was 17 of 223 (8.0%). Thus, if total fetal loss is taken as the index, there appears to be little difference between the two centres. The clinical controversy on the timing and method of birth in the different centres will continue - pundits can be conservative as well as radical, and, as Dr. Drury remarks, the truth probably lies somewhere in between. The bottom line in reports on the management of diabetes in pregnancy used to be the perinatal mortality (from 28 weeks gestation to the end of the first week of life). With the continuing improvement in neonatal care, more babies who would have died during the perinatal period are surviving beyond the seventh day of life. As a result, their subsequent deaths are not recorded in many publications. Even greater emphasis will fall on the quality of life for those infants surviving with a major congenital abnormality (heart and neural tube defect) which produces profound childhood morbidity. Prevention of these congenital abnormalities is the most important aim of pre- and early conceptional care of the diabetic mother. Both centres which report their recent results in this issue would agree that there has been an improvement even in the past 5 years — the problem is to define exactly which developments account for the change for the better, and which previously-trusted techniques can safely be allowed to fall by the wayside.