In the recent paper of Khoo and Lee titled ‘Acute diabetes complications in pregnancy’ (p 887–8), there are some discrepancies with respect to the literature.

1. According to Ref. 21 (Savage) ‘Diabetic ketoacidosis is a medical emergency with a significant morbidity and mortality’ in Khoo and Lee, immediately life threatening is the most severe stage of ketoacidosis, which is coma. The authors write (p 887), “The acute management of DKA during pregnancy is similar to that non-pregnant and has been reviewed elsewhere (Carroll and Yeomans 2005 and Kamalakannan et al. 2003).” However, more recent studies have shown fundamental progress in the understanding of pathogenesis and therapy of coma. According to Edge et al. and Nyenwe et al., the immediate cause of decreased level of consciousness including coma is very low blood pH (= high concentration of hydrogen ions, H ⁺ ). The glycolytic enzyme phosphofructokinase is pH-dependent, with decreasing pH also decreasing its activity and, thus, glucose utilisation in brain cells is impaired. This makes it possible to explain why infusions of sodium bicarbonate have decreased the lethality of coma in DKA to 0% (e. g., Ref. ).

2. The authors also write “Treatment includes insulin infusions… when the blood glucose falls below 14 mmol/l, infusions of dextrose solution should commence…” (p 887). Since the Nobel prize in 1977 to Rosalyn Yallow for new methods of biochemical analysis which make it possible to measure the concentration of insulin in human plasma, this is used worldwide. If in a diabetic patient hyperinsulinaemia is suspected, a necessary step is to measure the plasmatic concentration of insulin with adjustment of therapy to its result.