Dear Professor Robinson,

Paper: Gestational IGT does not increase perinatal mortality in a
developing country with high prevalence of glucose intolerance.

Thank you for asking me to review this paper on gestational diabetes. I think it is a nicely constructed paper with the important message that further work on gestational diabetes is needed before the current management of intensive investigation can be completely justified. A few minor changes will be needed but otherwise I think the paper would be important both to obstetricians, physicians and general practitioners, as well as to those making the policies and decisions about funding in diabetes.

I have also complied with the study by emailing my review as requested.

Yours sincerely
DEREK J TUFFNELL
Consultant Obstetrician and Gynaecologist
Enc

Paper: Gestational IGT does not increase perinatal mortality in a developing
country with high prevalence of glucose intolerance.

The topics covered by this paper are important. The title does not emphasize the fact that this paper also includes details about the outcome of women with pre-gestational diabetes. This element of the paper is important because it shows that within this population there is still a very poor outcome to pregnancy complicated by diabetes but that with merely impaired glucose tolerance the outcome is no worse than in women without glucose intolerance. The paper adds to existing knowledge as it is one of the few that has divided women with abnormalities of glucose tolerance in pregnancy into pre-gestational diabetes, gestational diabetes and gestational impaired glucose tolerance. The paper reads well and makes sense. There are two minor amendments that would need to be made. On page 6, when describing the criteria for gestational diabetes, the phrase "any two" should read "both" as there are only two. Also in the discussion on page 12 it suggests that the perinatal mortality is 10% in North West and North East England when in fact it is 1%.

ORIGINALITY

This work is original in terms of the Mauritian population. The rate of mother countries is referenced well within the paper. It does add to the published literature, as I stated in my previous paragraph, because it also includes a division between impaired glucose tolerance and diabetes developing in pregnancy.

IMPORTANCE OF THE WORK TO GENERAL READERS

This work is important to the general readers. Diabetes is seen as a health priority. Although this paper has the main message that impaired glucose tolerance is not as important to pregnancy outcome as diabetes, it also has the message that diabetes still has a very poor outcome in pregnancy. It is important to clinicians as it should remind them that there is a lack of evidence for the current plan of management for women with impaired glucose tolerance in pregnancy. It should encourage policy-makers to move towards continued research into ways to improve the outcome for women with diabetes and to earlier detection of diabetes in pregnancy but also as to whether it is appropriate to intervene in women with impaired glucose tolerance in pregnancy.

SCIENTIFIC RELIABILITY

This observational study is well designed and an adequate control group is included to allow comparison. There is also good referencing to other relevant papers and I can find no papers that I think should also be referenced. The only weakness of the paper is that there is nowhere in it the discussion that there may be some value in detecting impaired glucose tolerance in pregnancy as a risk factor for the development of diabetes in later life. It may be that in the Mauritian population the lack of health care provision does not allow them to follow up on these women but in other populations this aspect of the detection of impaired glucose tolerance is relevant and should be mentioned.

DEREK J TUFFNELL
Consultant Obstetrician and Gynaecologist