Objective To investigate maternal, perinatal, and neonatal outcomes of pregnancies in women with type 1 diabetes in the Netherlands. Design Nationwide prospective cohort study. Setting All 118 hospitals in the Netherlands. Participants 323 women with type 1 diabetes who became pregnant between 1 April 1999 and 1 April 2000. Main outcome measures Maternal, perinatal, and neonatal outcomes of pregnancy. Results 84% (n = 271) of the pregnancies were planned. Glycaemic control early in pregnancy was good in most women (HbA 1c ≤ 7.0% in 75% (n = 212) of the population), and folic acid supplementation was adequate in 70% (n = 226). 314 pregnancies that went beyond 24 weeks' gestation resulted in 324 infants. The rates of pre-eclampsia (40; 12.7%), preterm delivery (101; 32.2%), caesarean section (139; 44.3%), maternal mortality (2; 0.6%), congenital malformations (29; 8.8%), perinatal mortality (9; 2.8%), and macrosomia (146; 45.1%) were considerably higher than in the general population. Neonatal morbidity (one or more complications) was extremely high (260; 80.2%). The incidence of major congenital malformations was significantly lower in planned pregnancies than in unplanned pregnancies (4.2% (n = 11) v 12.2% (n = 6); relative risk 0.34, 95% confidence interval 0.13 to 0.88). Conclusion Despite a high frequency of planned pregnancies, resulting in overall good glycaemic control (early) in pregnancy and a high rate of adequate use of folic acid, maternal and perinatal complications were still increased in women with type 1 diabetes. Neonatal morbidity, especially hypoglycaemia, was also extremely high. Near optimal maternal glycaemic control (HbA 1c ≤ 7.0%) apparently is not good enough.

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OBJECTIVES -To investigate the frequency of severe hypoglycemia (SH) and hypoglycemic coma during the first trimester of type 1 diabetic pregnancy and in the 4 months before gestation and to identify risk indicators predicting first trimester SH in a nonselected nationwide cohort of pregnant women with type 1 diabetes.RESEARCH DESIGN AND METHODS -We conducted a longitudinal cohort survey in 278 pregnant type 1 diabetic women using questionnaires at inclusion and at 17 weeks of gestation, addressing the frequencies of SH (i.e., external help required) and hypoglycemic coma, general characteristics, hypoglycemia awareness, blood glucose symptom threshold, and the Hypoglycemia Fear Survey.RESULTS -The occurrence of SH (including hypoglycemic coma) rose from 0.9 Ϯ 2.4 episodes per 4 months before gestation to 2.6 Ϯ 6.3 episodes during the first trimester (P Ͻ 0.001), including an increase in episodes of coma from 0.3 Ϯ 1.3 to 0.7 Ϯ 3.7 (P ϭ 0.03). The proportion of women affected by SH rose from 25 to 41% (P Ͻ 0.001). First-trimester SH was independently related to a history of SH before gestation (odds ratio CONCLUSIONS -In type 1 diabetic pregnancy, the risk of SH is increased already before pregnancy and rises further during the first trimester. A history of SH before gestation, longer duration of diabetes, an HbA 1c level Յ6.5%, and a higher total daily insulin dose were risk indicators predictive for SH during the first trimester. Further research should aim to elucidate how the benefits of strict glycemic control balance with the markedly increased risk of SH early in pregnancy.[ Diabetes Care 25:554 -559, 2002

ObjeCtiveTo perform an external validation and direct comparison of published prognostic models for early prediction of the risk of gestational diabetes mellitus, including predictors applicable in the first trimester of pregnancy. DesignExternal validation of all published prognostic models in large scale, prospective, multicentre cohort study. setting 31 independent midwifery practices and six hospitals in the Netherlands. PartiCiPantsWomen recruited in their first trimester (<14 weeks) of pregnancy between December 2012 and January 2014, at their initial prenatal visit. Women with pre-existing diabetes mellitus of any type were excluded. Main OutCOMe MeasuresDiscrimination of the prognostic models was assessed by the C statistic, and calibration assessed by calibration plots. results 3723 women were included for analysis, of whom 181 (4.9%) developed gestational diabetes mellitus in pregnancy. 12 prognostic models for the disorder could be validated in the cohort. C statistics ranged from 0.67 to 0.78. Calibration plots showed that eight of the 12 models were well calibrated.The four models with the highest C statistics included almost all of the following predictors: maternal age, maternal body mass index, history of gestational diabetes mellitus, ethnicity, and family history of diabetes. Prognostic models had a similar performance in a subgroup of nulliparous women only. Decision curve analysis showed that the use of these four models always had a positive net benefit. COnClusiOnsIn this external validation study, most of the published prognostic models for gestational diabetes mellitus show acceptable discrimination and calibration. The four models with the highest discriminative abilities in this study cohort, which also perform well in a subgroup of nulliparous women, are easy models to apply in clinical practice and therefore deserve further evaluation regarding their clinical impact. IntroductionIn the field of obstetrics, the number of publications on prognostic models has more than tripled in the past decade, 1 which reflects an increasing interest in risk based medicine. Risk based medicine aims to provide the most appropriate care to each patient, often guided by outcome risk estimates based on individual patient characteristics, test results, or even genetic information. 2 As a result of the obesity pandemic, the incidence of gestational diabetes mellitus, notably occurring in the second or third trimester, is rising and is increasingly contributing to perinatal complications such as macrosomia, shoulder dystocia, caesarean section, and neonatal hypoglycaemia. 3 4 Moreover, long term sequelae of gestational diabetes mellitus are type 2 diabetes in mothers and obesity in their offspring. 5 6 Early diagnosis and treatment of gestational diabetes mellitus have been proven to improve pregnancy outcomes. 7 8 Some guidelines propose a population strategy for diagnosing the disorder [9][10][11][12] (that is, an oral glucose tolerance test) in all pregnant women, whereas others opt for a high ri...