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Glucagon treatment requires a manually dexterous 'operator' who is composed, confident and competent in the whole procedure. Anecdotal reports from parents of teenagers describing difficulties in administering this procedure during severe hypoglycaemia led us to investigate the 'techniques' of 136 parents (106 parents of teenagers and 30 parents of young children). A simulated administration by parents using Novo Nordisk Glucagen 1 Hypokits was timed, rated and compared with a group of diabetes health professionals. Parent's 'real life' experiences of education and administration were obtained with a standard questionnaire. Glucagon residues in syringes and vials were estimated in a laboratory. Sixty nine per cent had handling difficulties ranging from opening the container to drawing the correct dose into the syringe. There was no statistical difference in time taken to complete the procedure between the two parent groups. However there was a significant difference between parents and the professional group. Parents were not accurate in administering dosages as recommended. Young children weighing more than 25 kg would have received less than the required dose. All parents reported verbal instruction with demonstration of the procedure at initial education. We suggest that glucagon administration needs to be taught 'hands on' and the skill reassessed on an annual basis.

The ratio of blood ketone bodies 3-hydroxybutyrate to acetoacetate, once thought to be fairly constant, has been shown to vary from 0.6:1 to 4.8:1. In untreated, ketoacidotic patients, it is directly related to the plasma free fatty acid level. Administration of insulin lowers the ratio because the fall of blood 3-hydroxybutyrate occurs earlier and more rapidly than that of acetoacetate. During the treatment of ketoacidosis there is usually an initial increase of the acetoacetate which may persist at a high levelfor several hours despite improvement of the patient and falling 3-hydroxybutyrate and glucose levels.

Pregestational diabetes mellitus (DM) is associated with adverse fetal and maternal outcomes. Studies suggest that optimal control of diabetes before and during pregnancy minimises these risks. There are few recent reviews of outcomes of pregnancies complicated by DM in Australia. Ninety-three pregnancies in women with DM at our hospital since 1989 were identified. We collected data for maternal age, type of diabetes, duration of therapy, complications of diabetes, maternal complications of pregnancy and fetal outcomes including malformations. The rate of pregnancy planning with optimal glycaemic control at conception was low in our population, particularly in patients with Type 1 diabetes. Women who smoked had worse glycaemic control, and a higher rate of miscarriage. There was a high rate of Caesarean section, particularly in those women with Type 1 diabetes (77.4%). The rate of Caesarean section was lower in planned pregnancies. There were no perinatal deaths. The number of neonates with major congenital anomalies was high (13%) in the Type 1 population. It is important to increase the rates of prepregnancy planning and to optimise glycaemic control before pregnancy. In many cases there has been a long interval between diagnosis and pregnancy, so all women with diabetes should receive counselling at frequent intervals about pregnancy and the importance of planning. Women who planned their pregnancies had improved outcomes, with decreased rate of Caesarean section, better glycaemic control and better neonatal Apgar scores. Women with diabetes should not smoke during pregnancy because of the increased risk of miscarriage and poorer glycaemic control.

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