1479
are now feasible, and many of us believe that nicotinamide and insulin are the first agents that should be tested. The European Nicotinamide Diabetes Intervention Trial (END IT) has received support from paediatric diabetologists across Europe, organised into sixteen national groups, and (despite Brook’s doubts) the first wave of volunteers includes many medical families. Effective prevention of childhood diabetes will no doubt take years to achieve, and research into prevention and palliation of late complications must and will continue to receive high priority. But research groups will continue to home in on diabetes prevention-and for the reason that Willie Sutton robbed banks, "that’s where the money is".
Department of Diabetes and Metabolism Andrew Cudworth Laboratories, St Bartholomew’s Hospital Centre for Clinical Research, London EC1A 7BE, UK
Glucose and insulin infusions
EDWIN A. M. GALE
during labour
of pregnancy in women with diabetes has in the past fifty years, mainly because of careful attention to blood glucose control It is still considered standard practice to use a glucose and insulin infusion during labour, to maintain such control until delivery. However, some women with insulin-dependent diabetes seek greater freedom of movement during labour and question the routine requirement for infusions. One of us (A. K.), herself having insulin-dependent diabetes, gave birth without an infusion during labour.3We have surveyed all UK diabetologists to determine their practice and their experience in the management of women with diabetes during labour. A postal questionnaire was sent to 422 physicians in all 218 health districts and health boards in the UK, requesting details of numbers of patients with diabetes delivering each year, and methods of managing labour in these women. The absence of a register of diabetic deliveries in many hospitals suggests that these questionnaires may have been completed predominantly from memory. The questionnaires asked for a telephone number for one of us to discuss the responses, and all physicians who indicated that they had managed labour without an intravenous insulin infusion were contacted for further details. Replies were received from 174 diabetologists (41 2 % ), for whom the district was identifiable in 165, these representing 128 districts (or 58-7% of all health districts and boards). Those replying estimated that they managed a mean of 20 pregnancies per year, around three-quarters of these being in established insulindependent diabetic women (45 %) or in insulin-treated non-insulindependent or gestational diabetic women (32%). 152 respondents (87%) routinely used a glucose and insulin infusion in labour. Most cited the reason as being "standard practice" or "difficulty in managing without a drip". The 22 diabetologists (13%) not routinely using an infusion cared for an estimated 85 patients (1-2% of estimated deliveries) in the previous 2 years without an infusion. In most instances, the reasons for not setting up an infusion were that the women had gestational diabetes and/or had taken their insulin before arrival; a glucose infusion was used instead in around half these. 4 diabetologists (2-3%) had electively managed labour in 8 insulin-dependent diabetic women (0-5%) without an infusion of glucose and insulin. The regimen used was 4-6-hourly subcutaneous soluble insulin injections in 7 patients, and continuous subcutaneous insulin infusion in 1 patient. Sips of glucose-containing fluids were taken as necessary to maintain target blood-glucose concentrations of between 4 and 8 mmol/1. In all cases, the outcome of pregnancy was a live delivery without major neonatal problems. The figure shows the details of blood glucose control during 2 deliveries of a single insulin-dependent diabetic woman aged 31 at the time of her first delivery. While a therapeutic trial would be necessary to compare outcome with the standard and advocated approachessuch studies would present major difficulties of organisation and implementation. It seems clear from this survey, however, that insulin-dependent diabetic women wishing to give birth without a glucose and insulin infusion would find it difficult to do so in most health districts in the UK. A glucose and insulin infusion provides several advantages in
SiR,—The
outcome
improved remarkably
Details of 2 deliveries without glucose and insulin infusions.
Upper, 38 weeks; lower, 39 + weeks. of ease of administration and simplicity of approach, and it be used by staff who may not be experts in diabetes management. Furthermore, infusions can be continued throughout a long labour, without anxieties about induction of anaesthesia should this become necessary. Nevertheless, the experience of 8 women we have identified, all of whom had successful deliveries with no adverse consequences, suggests that in a motivated and healthy insulin-dependent diabetic woman with an uncomplicated pregnancy, who is prepared to have multiple subcutaneous insulin injections, an infusion need not be part of routine practice. terms can
Academic Unit of Diabetes and Endocrinology,
Whittington Hospital, London N19 5NF, UK
JOHN S. YUDKIN
Diabetic Pregnancy Network, British Diabetic Association
ANNA KNOPFLER
1. Drury MI. They give birth astride of a grave. Diabetic Med 1989; 6: 291-98. 2. Lean MEJ, Pearson DWM, Sutherland HW. Insulin management during labour and delivery in mothers with diabetes. Diabetic Med 1990; 7: 162-64. 3. Knopfler A. Diabetes and pregnancy. London: Macdonald, 1989. 4. Gardosi J, Hutson N, B-Lynch C. Randomised, controlled trial of squatting in the second stage of labour. Lancet 1989; ii: 74-77.
Non-sexual
papillomavirus transmission routes
SIR,--Compelling evidence now associates specific types of human papillomavirus (HPV) infection as the sexually transmitted cause of proliferative lesions of the anogenital tract epithelium. The very sensitive polymerase chain reaction (PCR) method for HPV detection confirms that genital HPV infections are mainly transmitted in adults by sexual contact.2,3However, other lines of evidence suggest acquisition of genital HPV, at least in children, by other means.4-6 To ascertain the possibility of non-sexual transmission of genital HPV in adults, we have analysed the prevalence of HPV by PCR in 61 women in their mid-20s with no experience of sexual intercourse and in another 57 women with sexual experience. All 118 women attended a clinic providing the compulsory premarital examinations
are now feasible, and many of us believe that nicotinamide and insulin are the first agents that should be tested. The European Nicotinamide Diabetes Intervention Trial (END IT) has received support from paediatric diabetologists across Europe, organised into sixteen national groups, and (despite Brook’s doubts) the first wave of volunteers includes many medical families. Effective prevention of childhood diabetes will no doubt take years to achieve, and research into prevention and palliation of late complications must and will continue to receive high priority. But research groups will continue to home in on diabetes prevention-and for the reason that Willie Sutton robbed banks, "that’s where the money is".
Department of Diabetes and Metabolism Andrew Cudworth Laboratories, St Bartholomew’s Hospital Centre for Clinical Research, London EC1A 7BE, UK
Glucose and insulin infusions
EDWIN A. M. GALE
during labour
of pregnancy in women with diabetes has in the past fifty years, mainly because of careful attention to blood glucose control It is still considered standard practice to use a glucose and insulin infusion during labour, to maintain such control until delivery. However, some women with insulin-dependent diabetes seek greater freedom of movement during labour and question the routine requirement for infusions. One of us (A. K.), herself having insulin-dependent diabetes, gave birth without an infusion during labour.3We have surveyed all UK diabetologists to determine their practice and their experience in the management of women with diabetes during labour. A postal questionnaire was sent to 422 physicians in all 218 health districts and health boards in the UK, requesting details of numbers of patients with diabetes delivering each year, and methods of managing labour in these women. The absence of a register of diabetic deliveries in many hospitals suggests that these questionnaires may have been completed predominantly from memory. The questionnaires asked for a telephone number for one of us to discuss the responses, and all physicians who indicated that they had managed labour without an intravenous insulin infusion were contacted for further details. Replies were received from 174 diabetologists (41 2 % ), for whom the district was identifiable in 165, these representing 128 districts (or 58-7% of all health districts and boards). Those replying estimated that they managed a mean of 20 pregnancies per year, around three-quarters of these being in established insulindependent diabetic women (45 %) or in insulin-treated non-insulindependent or gestational diabetic women (32%). 152 respondents (87%) routinely used a glucose and insulin infusion in labour. Most cited the reason as being "standard practice" or "difficulty in managing without a drip". The 22 diabetologists (13%) not routinely using an infusion cared for an estimated 85 patients (1-2% of estimated deliveries) in the previous 2 years without an infusion. In most instances, the reasons for not setting up an infusion were that the women had gestational diabetes and/or had taken their insulin before arrival; a glucose infusion was used instead in around half these. 4 diabetologists (2-3%) had electively managed labour in 8 insulin-dependent diabetic women (0-5%) without an infusion of glucose and insulin. The regimen used was 4-6-hourly subcutaneous soluble insulin injections in 7 patients, and continuous subcutaneous insulin infusion in 1 patient. Sips of glucose-containing fluids were taken as necessary to maintain target blood-glucose concentrations of between 4 and 8 mmol/1. In all cases, the outcome of pregnancy was a live delivery without major neonatal problems. The figure shows the details of blood glucose control during 2 deliveries of a single insulin-dependent diabetic woman aged 31 at the time of her first delivery. While a therapeutic trial would be necessary to compare outcome with the standard and advocated approachessuch studies would present major difficulties of organisation and implementation. It seems clear from this survey, however, that insulin-dependent diabetic women wishing to give birth without a glucose and insulin infusion would find it difficult to do so in most health districts in the UK. A glucose and insulin infusion provides several advantages in
SiR,—The
outcome
improved remarkably
Details of 2 deliveries without glucose and insulin infusions.
Upper, 38 weeks; lower, 39 + weeks. of ease of administration and simplicity of approach, and it be used by staff who may not be experts in diabetes management. Furthermore, infusions can be continued throughout a long labour, without anxieties about induction of anaesthesia should this become necessary. Nevertheless, the experience of 8 women we have identified, all of whom had successful deliveries with no adverse consequences, suggests that in a motivated and healthy insulin-dependent diabetic woman with an uncomplicated pregnancy, who is prepared to have multiple subcutaneous insulin injections, an infusion need not be part of routine practice. terms can
Academic Unit of Diabetes and Endocrinology,
Whittington Hospital, London N19 5NF, UK
JOHN S. YUDKIN
Diabetic Pregnancy Network, British Diabetic Association
ANNA KNOPFLER
1. Drury MI. They give birth astride of a grave. Diabetic Med 1989; 6: 291-98. 2. Lean MEJ, Pearson DWM, Sutherland HW. Insulin management during labour and delivery in mothers with diabetes. Diabetic Med 1990; 7: 162-64. 3. Knopfler A. Diabetes and pregnancy. London: Macdonald, 1989. 4. Gardosi J, Hutson N, B-Lynch C. Randomised, controlled trial of squatting in the second stage of labour. Lancet 1989; ii: 74-77.
Non-sexual
papillomavirus transmission routes
SIR,--Compelling evidence now associates specific types of human papillomavirus (HPV) infection as the sexually transmitted cause of proliferative lesions of the anogenital tract epithelium. The very sensitive polymerase chain reaction (PCR) method for HPV detection confirms that genital HPV infections are mainly transmitted in adults by sexual contact.2,3However, other lines of evidence suggest acquisition of genital HPV, at least in children, by other means.4-6 To ascertain the possibility of non-sexual transmission of genital HPV in adults, we have analysed the prevalence of HPV by PCR in 61 women in their mid-20s with no experience of sexual intercourse and in another 57 women with sexual experience. All 118 women attended a clinic providing the compulsory premarital examinations
